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WORKS   BY  MR.  B.  G.  A.  MOYNIHAN 


Retroperitoneal  Hernia.      London,  1899 
Bailliere,  Tindall  &  Cox 

The  Surgical  Treatment  of  Gastric  and  Duodenal 
Ulcers.  W.  B.  Saunders  &  Co.,  1903 

Gall-Stones  and  their  Surgical  Treatment 
Second  Edition,   1  \Y.  B.  Saunders  &  Co. 

Abdominal  Operations 
Second  Edition,  1906  W.  B.  Saunders  Company 

Duodenal  Ulcer 
Second  Edition,  1912  \\  .  B.  Saunders  Company 

Pathology  of  the  Living  and  other  Essays.     W.    B. 
Saunders    Company,  1910 


Willi    MR.    MAYO    KOBSON 

Diseases  of   the  Stomach.  Second  Edition,  1905 

Diseases  of  the  Pancreas.     W.    B.   Saunders  &  Co. 

[902 


Duodenal  Ulcer 


B.  G.  A.  MOYNIHAN,  M.S.  (Lond.),  F.R.C.S. 

LEEDS 


SECOND   EDITION,   ENLARQED 
ILLUSTRA TED 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1912 


Copyright,  ioio,  by  \Y.  B.  Saunders  Company 
Revised,  reset,  and  recopyrighted,  February.  lyi  > 


Copyright,  1912,  by  W.  B,  Saunders  Company 


PHI  N  T  ED 


TO 

D.  W.  M. 
S.  B.  M 
P.  B.  M. 


The  longer  I  live  the  more  I  am  convinced  that  the  apothe- 
cary is  of  more  importance  than  Seneca,  and  that  half  the  un- 
happiness  in  the  world  proceeds  from  little  stoppages,  from  a 
duct  choked  up,  from  food  pressing  in  the  wrong  place,  from  a 
vexl  duodenum  or  an  agitated  pylorus. 

— Sydney  Smith  ("Memoirs."  by  Lady  Holland,  page  85). 


PREFACE  TO  THE  SECOND  EDITION 


The  changes  in  the  text  in  the  second  edition  of  this 
work  have  been  chiefly  concerned  with  the  differential 
diagnosis  of  duodenal  ulcer  and  the  result  of  .r-ray 
examinations  of  the  stomach  after  the  administration  of 
bismuth. 

I  have  thought  it  better  to  include  the  cases  operated 
upon  in  the  years  1909  and  1910  in  a  separate  appendix, 
so  that  the  results  of  the  earlier  and  later  experiences 
may  be  contrasted  and  compared.  For  this  second 
appendix  also  Mr.  Harold  Collinson  is  responsible.  Tin- 
additional  drawings  have  been  made  by  Miss  Ethel  M. 
Wright.  To  these  two  loyal  helpers  I  am  again  deeply 
indebted. 

B.  G.    A.    MOYNIHAN. 
3,3  Park  Square,  Leeds. 

February,  191 2. 


PREFACE 


Among  the  many  and  great  developments  of  modern 
abdominal  surgery,  few  of  the  problems  which  were  to 
be  unravelled  have  proved  more  interesting  than  that 
concerned  with  duodenal  ulcer.  Ten  years  ago  ulcera- 
tion of  the  duodenum  was  looked  upon  as  a  rare  disease, 
and  its  confident  recognition  during  life  was  believed  to 
be  hardly  possible.  To-day  we  know  that  this  disease  is 
common,  and  its  discovery  in  the  majority  of  cases  pre- 
sents no  great  difficulties  to  the  trained  clinician.  In 
my  own  experience  the  diagnosis  of  duodenal  ulcer  is 
made  with  a  degree  of  accuracy  that  is  not  exceeded  in 
the  case  of  any  other  abdominal  disorder. 

Perhaps  the  most  remarkable  feature  in  the  history  of 
this  condition  is  the  fact  that  its  main  symptoms  have 
through  generations  of  text-books  been  ascribed  without 
reserve  or  hesitation  to  the  existence  not  of  an  organic 
but  of  a  purely  functional  disturbance.  The  varied  and 
accumulating  experience  of  a  few  surgeons  soon  led,  how- 
ever, to  the  conviction  that  the  range  of  functional  dis- 
orders of  the  stomach  must  for  the  future  be  greatly 
narrowed,  that  not  a  few  of  the  so-called  "neuroses"  of 
the  stomach  were  veritable  examples  of  structural 
changes  having  their  seat  in  the  stomach,  duodenum,  gall- 
bladder,  or  appendix.     The  term  "dyspepsia"  as  used  l»\ 

1 1 


12  Preface 

the  older  writers  included  every  form  of  disorder  in  which 
the  activity  of  the  digestive  processes  seemed  impaired. 
In  this  great  group  of  conditions,  believed  to  be  chiefly 
or  entirely  functional,  we  now  recognise  that  probably 
the  majority  of  cases  are  due  to  organic  diseases  affecting 
not  the  stomach  only,  but  also  and  more  frequently  the 
various  organs  I  have  named.  The  symptoms  which  the 
older  physicians  believed  to  be  due  to  derangement  of 
the  functions  of  the  stomach  the  surgeon  has  shewn  to 
be  caused  by  changes  in  the  texture  of  one  or  other  of 
these  several  organs. 

Among  all  these  forms  of  organic  disease,  duodenal 
ulcer  stands  out  the  clearest.  We  are  now  familiar  with 
its  symptoms,  we  have  learnt  of  its  dangers,  we  are  well 
equipped  with  the  means  of  treating  it  writh  permanently 
satisfactory  results. 

One  result  of  this  surgical  discovery  must  be  that  the 
physician  now  knowing  well  that  which  formerly  was  not 
suspected,  namely,  the  attachment  of  the  symptoms  he 
recognises  to  an  organic  lesion,  will  insist  upon  a  much 
stricter  and  a  more  prolonged  medical  treatment,  and  in 
this  way  it  is  probable,  and  is  sincerely  to  be  hoped,  that 
some  at  least  of  the  cases  which  now  seek  help  at  the 
hands  of  the  surgeon  may  be  permanently  relieved  of 
their  sufferings  by  this  greater- care,  and  escape  the  need 
of  operative  attentions. 

In  the  appendix  to  this  work  all  the  cases  of  duodenal 
nicer  upon  which  I  had  operated  up  to  the  end  of  1908 
have  been  analysed  by  my  colleague,  Mr.  Harold  Collin- 
son.  A  study  of  this  record  will,  I  think,  support  the 
claim  that  the  surgical  treatment   of  duodenal  ulcer  is 


Preface  13 

becoming  as  safe  as  can  be  expected  of  an  abdominal 
operation  of  this  magnitude,  performed  sometimes  upon 
patients  greatly  enfeebled  by  loss  of  blood,  or  by  the 
inability  to  eat  sufficient  for  their  needs.  Up  to  the  end 
of  1909  the  mortality  of  the  whole  series  of  my  cases  was 
1.6  per  cent.,  and  among  the  last  121  cases  there  was 
no  death. 

My  very  sincere  thanks  are  due  to  my  colleague,  Mr. 
Harold  Collinson,  for  his  help,  not  only  in  the  literary, 
but  also  in  much  of  the  operative,  work.  He  has  helped 
me  ungrudgingly  at  every  opportunity. 

The  illustrations  have  been  drawn  for  me  by  Miss 
Ethel  M.  Wright,  to  the  excellence  of  whose  work  I  am 
now,  as  in  my  earlier  works,  much  indebted.  The  photo- 
graphs have  been  taken  from  museum  specimens  by  Mr. 
Henry  George  and  by  Messrs.  Godart  &  Co.  I  am  glad 
to  be  able  to  speak  of  the  kindness  and  courtesy  with 
which  every  curator  placed  his  specimens  at  my  dis- 
posal. The  name  of  the  museum,  the  number  of  the 
specimen,  and  the  catalogue  descriptions  are  given  in 
every  case. 

My  secretary,  Miss  J.  Mackill,  has  given  me  constant 
help,  for  which  I  wish  to  express  my  thanks. 

B.   G.   A.    MOYNIHAN. 
33  Park  Square,  Leeds. 


CONTENTS 


CHAPTER  I  PAGE 

History 17 

CHAPTER  II 

Ulceration  of  the  Duodenum  in  Cases  of  Burns  or  Scalds.  ...  24 

Position  and  Character  of  the  Ulcer.  . .  .  ! 38 

Symptoms 41 

CHAPTER  III 
Ur.emic  Ulcer  of  the  Duodenum 44 

CHAPTER  IV 

Tuberculous  Ulceration  of  the  Duodenum 68 

Duodenal  Ulcers  Associated  with  Tuberculosis 75 

CHAPTER  V 

Mel/ENa  Neonatorum  and  Duodenal  Ulcer 85 

Symptoms  and  Diagnosis 89 

Treatment   91 

CHAPTER  VI 
Chronic  Duodenal  Ulcer— Symptoms  and  Diagnosis     107 

CHAPTER  VII 

Differential  Diagnosis 139 

CHAPTER  VIII 

Treatment  of  Chronic  Duodenal  1  'i.ckk   158 

Surgical  Treatment  of  Chronic  Duodenal  Ulcer   160 

(  HAPTER  IX 
Jejunal  and  Gastro  [eji  nal  Ulcer  196 

CHAPTER  X 

Perforation -'  1 5 

Acute  Ulcer 215 

Chronic  Ulcer  2l6 

'5 


1 6  Contents 

Perforation  (Continued)  page 

Differential  Diagnosis 225 

Treatment   233 

Subacute  Perforation 242 

Chronic  Perforation 247 

CHAPTER  XI 
Pathology  of  Chronic  Duodenal  Ulcer 264 

APPENDIX   I 
A   Detailed  Statement  of  all  Cases  Operated  Upon  to  the 

End  of  1908;  with  an  Analysis  and  Summary 317 

Complete   List   of   Cases  of   Chronic    Duodenal   Ulcer  Treated 

by  Operation 335 

APPENDIX  II 
Additional  Cases  Operated  Upon  in  1909  and  1910 428 


I  ndex  of  Authors 467 


Index 


473 


DUODENAL  ULCER 


CHAPTER  I 

HISTORY 

The  earliest  mention  of  duodenal  ulcer  in  medical 
literature  occurs  in  the  London  "  Medico-chirurgical 
Transactions"  of  1817  (viii,  232).  Mr.  Travers  there 
reports  the  following  cases: 

Case  i. — Mr.  ,  aged  thirty-five,  of  a  strumous  habit, 

but  enjoying  generally  good  health,  was  seized  whilst  dining 
in  company  with  an  excruciating  pain  in  the  abdomen,  which 
he  described  as  unlike  any  he  had  ever  felt.  The  principal 
seat  of  his  pain,  which  never  remit  ted,  was  the  region  oi  the 
navel,  and  it  was  described  as  occasionally  shooting  from  this 
part  as  from  a  centre  over  hi--  whole  body,  and  especially 
affecting  his  neck  and  shoulders.  His  abdomen  was  tense  and 
hard;  his  respiration  somewhat  agitated;  his  pulse  little,  it 
at  all,  affected.  Flatus  rose  in  quantity  from  his  stomach, 
but  he  had  no  disposition  to  vomit.  At  midnight  the  medi- 
cine, which  he  had  taken  soon  after  the  attack,  had  not  oper- 
ated; he  was  exceedingly  restless,  unable  to  bear  the  slightesl 
pressure  of  the  hand  upon  the  abdomen,  and  earnestly  prayed 
to  be  relieved  from  his  intolerable  anguish  by  death.     I  le  often 

called    for  a   spoonful   of  gruel,   which   in    part    returned,   as  it 

deglutition  was  interrupted  by  a  spasm  of  the  a  sophagus.  At 
3  a.  m.  the  pain  was  not  mitigated;  the  pulse  was  quick,  small, 
and  fluttering.  His  intellect  remained  clear  and  perfect,  but 
his  strength  was  rapidly  exhausting;    his  extremities  became 

cold,  and  he  died  in  ,1  warm  bath  at  6  A.  M.,  about  thirteen 
hours  after  the  at  tack  ol  pain. 

2  17 


i  8  Duodenal  Ulcer 

I  pas-  over  the  formalities  of  medical  treatment;  suffice  it 
to  say  that  all  the  obvious  means  of  relict"  were  perseveringly 
employed  without  any  sensible  effect. 

Inspection  of  the  Body. — The  peritoneum  was  universally 
inflamed;  recent  adhesions  attached  the  contiguous  folds  of 
the  intestines  to  each  other;  a  large  quantity  of  fluid  deeply 
tinged  with  bile  was  contained  in  the  pelvis;  and  about  a 
finger's  breadth  below  the  pylorus  appeared  a  circular  fora- 
men, having  a  peritoneal  margin,  of  the  diameter  of  a  writing- 
pen.  It  proved  to  be  the  centre  of  an  irregular  superficial 
ulcer  of  the  mucous  coat,  including  in  its  extent  two-thirds  of 
the  ring  of  the  pylorus.  There  was  no  other  appearance  of 
ulceration  in  the  intestinal  canal. 

CASE  2.  Mills,  a  hairdresser,  had  occasionally  for  the 
seven  preceding  years  suffered  sudden  and  very  violent  at- 
tacks of  abdominal  pain,  from  which  he  had  always  been 
speedily  relieved  by  a  wineglassful  of  brandy.  On  the  day  of 
the  fatal  attack  hi'  had  endured  without  interruption,  attend- 
ing to  his  business,  and  in  the  evening  went  to  the  market  to 
buy  fish  for  his  supper.  On  his  return  the  pain  became  in- 
tolerable, and  he  took  the  usual  dose  of  brandy,  but  did  not 
obtain  from  it  the  expected  relief;  he  sat  in  a  bent  posture, 
with  a  sunken  countenance  expressive  of  much  agony.  Now 
and  then  he  vomited.  He  dreaded  going  upstairs,  but  it 
length,  making  a  desperate  effort,  he  ran  up,  and  fell  as  he 
entered  his  room.  It  was  evident  that  he  was  inflamed  at 
this  time,  and  the  branch-  appears  to  have  aggravated  the 
symptoms.  He  died  in  thirty-six  hours  from  the  commence- 
ment of  acute  pain  ;  every  part  of  the  peritoneum  was  inflamed; 
a  circular  aperture  of  the  peritoneum  large  enough  to  admit 
a  crow's  quill  was  found  at  the  junction  of  the  duodenum  and 
stomach.  It  was  the  centre  of  an  ulcer  that  had  destroyed 
thi!  villous  and  muscular  coat-  of  the  bowel  to  the  extent  of 
half  an  inch.  (  oagulable  lymph  was  effused  about  the  py- 
lorus, but  not  in  quantity  sufficient  to  produce  an  adhesion  of 
the  adjoining  parts,  so  as  to  exclude  the  aperture  from  the 
cavity  of  the  peritoneum.  The  margin  of  the  aperture  was 
deeply  tinged  with  bile,  yet  the  contents  of  the  peritoneum 
had  only  the  appearance  common  to  matters  effused  from  in- 


History  19 

flamed  serous  membrane.  Although  the  unhappy  man  had 
provided  himself  with  food,  it  did  not  appear  that  he  had 
taken  any;  but  it  is  probable  the  peritoneal  sac  had  been 
injected  with  brandy. 

In  the  second  edition  of  "Pathological  and  Practical 
Research  on  Diseases  of  the  Stomach,"  etc.,  by  Dr. 
John  Abercrombie  (Edinburgh,  1830,  pp.  103  et  seq.), 
five  cases  stored  in  the  literature  are  collected  together. 
One  was  recorded  by  Irvine,  of  Philadelphia,  in  1824. 
a  characteristic  example  of  a  chronic  tuberculous  ulcer; 
two  by  French  physicians;  and  two  were  related  in 
the  "Midland  Medical  and  Surgical  ^Reporter"  (May 
and  November,  1829).  In  addition,  a  specimen  in  the 
Museum  of  the  Royal  College  of  Surgeons  of  Edinburgh 
is  mentioned,  in  which  perforation  had  occurred.  Dr. 
Abercrombie  remark-:  "The  leading  peculiarity  of 
disease  oi  the  duodenum,  so  far  as  we  arc  at  present 
acquainted  with  it,  seems  to  be  that  the  food  is  taken 
with  relish,  and  the  first  stage  of  digestion  is  not  impeded  ; 
but  the  pain  begins  about  the  time  when  the  food  is 
passing  out  of  the  stomach,  or  from  two  to  four  hours 
after  a  meal."  This  observation  seems  to  have  attracted 
no  attention,  and  never  since  to  have  been  recalled. 
The  first  paper  specially  devoted  to  this  subject  appeared 
in  1861;  it  dealt  solely  with  perforating  ulcer,  and  notes 
were  given  of  3  cases  observed  1>\  the  author,  and  of 
10  collected  from  the  literature  (Klinger  (Wiirzbui 
"Arch.  f.  phys.  Heilk.,"  iN01.ii.5j.  In  [863twomono- 
graphs  appeared,  one  1>\  Falkenbach,  "De  ulcere 
duodenali  chronico"  (Berlin,  [86i  ;  the  other  and 
more    important    by    Dr.    F.     Trier,    "  Ileus    corrosivuni 


20  Duodenal  Ulcer 

duodeni"  (Copenhagen,  1863).  Trier's  paper  was  epit- 
omised in  the  "British  and  For.  Med.-Chi.  Review" 
of  January,  [864.  It  contained  a  report  of  all  cases 
then  on  record,  and  in  addition  a  series  of  26  cases, 
mostly  seen  in  the  Frederick  Hospital  of  Copenhagen, 
were  given  in  detail.  Professor  Trier,  of  Copenhagen, 
lias  kindly  translated  this  work  for  me,  and  I  found  the 
case  records  of  great  value.  The  work  is  certainly 
the  most  important  of  all  the  early  monographs.  In 
[865  appeared  Krauss'  "Das  perforirende  Geschwiir 
im  Duodenum"  (Berlin,  Aug.  Hirschwald).  In  this 
pamphlet  there  are  80  case  records,  for  the  most  part 
in  full  detail.  Between  1863  and  1882  a  series  of  Paris 
theses  appeared,  in  which  a  few  additional  cases  were 
recorded,  but  nothing  material  was  added  to  our  knowl- 
edge. In  1883  Chvostec  recorded  ("Allg.  Wien.  med. 
Zeitg.,"  xxvii,  =>33)  eight  personal  cases,  and  135  extracted 
from  published  records.  In  1887  Bucquoy  ("Arch. 
Gen.  de  Med.,"  i,  398  et  seq.)  published  an  article  to 
which  due  credit  has  hardly  yet  been  paid.  For  the 
first  time  he  made  a  diagnosis  of  five  cases  from  the 
symptoms  alone,  and  verification  in  one  was  subse- 
quently obtained  by  autopsy.  He  suggested  that  the 
symptoms  observed  in  cases  of  duodenal  ulcer  were 
sufficiently  precise  and  characteristic  to  enable  a  diag- 
nosis to  be  made.  Bucquoy  was,  I  think,  the  first 
physician  after  the  time  of  Abercrombie  to  suggest 
the  possibility  of  a  diagnosis  being  made  during  the 
life  of  the  patient.  In  [89]  Oppenheimer's  thesis  ("Das 
Ulcus  pepticum  duodenale,"  Wurzburg)  appeared;  it 
contained  a  summary   of   most    of   the   recorded   cases, 


History  21 

and  gave  useful  tables  of  them.  A  thesis  ("Etude  sur 
1'ulcere  simple  du  duodenum,"  Paris,  1894)  DY  Collin 
contained  a  summary  of  257  cases  recorded  up  to  that 
time  and  notes  of  5  cases  observed  by  the  author. 
Detailed  records  were  also  given  of  all  the  cases  recorded 
in  the  preceding  ten  years.  The  work  is  valuable,  and 
constant  reference  has  since  been  made  to  it.  In  the 
''Guy's  Hospital  Reports"  of  1893  there  appeared  a 
most  exhaustive  account  of  the  "Diseases  of  the  duo- 
denum," written  by  Dr.  Perry  (now  Sir  Cooper  Perry) 
and  Dr.  L.  Shaw.  The  records  of  17,652  autopsies 
performed  at  Guy's  Hospital  between  1826  and  1892 
furnished  the  material  from  which  the  work  was  built. 
There  is  no  better  presentation  of  the  subject  from  the 
pathological  standpoint,  and  the  whole  work  is  a  monu- 
ment of  industry.  Up  to  this  time  the  condition  of 
duodenal  ulcer  had  possessed  no  interest  for  the  surgeon. 
It  was  not  realised  that  the  acute  catastrophes  of  haemor- 
rhage or  perforation  fell  within  the  province  of  the 
surgeon,  nor  had  the  symptoms  of  the  chronic  ulcer 
been  recognized  with  sufficient  certainty  to  enable  a 
diagnosis  to  be  offered.  In  1894  Mr.  II.  P.  Dean 
recorded  the  first  successful  case  of  perforating  ulcer 
treated  by  operation  ("Brit.  Med.  Jour.,"  [894,  i,  1014); 
he  was  followed  by  Mr.  L.  A.  I  hum  I "  Brit.  Med.  Jour.," 
[896,  i,  846).  The  result  of  these  two  cases  drew  con- 
spicuous attention  to  the  subject,  and  other  successes 
quickly  followed.  An  excellent  summary  of  the  early 
cases,  together  with  a  critical  review  of  the  whole  subject 
of  perforating  duodenal  ulcers,  was  given  by  Weir  in  his 
presidential  address  to  the  American  Surgical  Associa 


22  Duodenal   Ulcer 

tion  I  •'  Med.  News,"  1900,  i,  690,  732).  (  For  a  complete 
early  list  sec  "Lancet,"  1901,  ii,  1656.)  The  surgical 
treatment  of  chronic  duodenal  ulcer  was  inaugurated  by 
A.  Codivilla  ("Sei  Casi  Gastroenterost  Sperimentale." 
Mem.:  Orig.  Firenza,  1893,  pp.  406-421,  and  "Contrib. 
alia  Chirurg.  gastrica,"  Bologna,  1898).  The  first 
case  was  operated  upon  on  March  22,  1893,  a  stenosis 
of  the  duodenum  two  fingers'  breadth  beyond  the  pylorus 
being  found.  The  patient,  aged  forty,  was  quite  well 
five  years  later.  The  second  case  was  operated  upon 
by  the  same  surgeon  on  May  5,  1898;  the  third  by 
Pagenstecher  in  1899  ("Deut.  Zeit.  f.  klin.  Chir.,"  1899, 
Hi,  569).  My  first  case  was  operated  upon  in  January, 
1900  ("Lancet,"  1905,  i,  340),  and  the  first  paper  deal- 
ing with  the  various  features  of  this  disease  considered 
from  the  standpoint  of  the  surgeon  was  written  by 
myself  in  1901  ("Lancet,"  1901,  ii,  1656). 

The  earliest  complete  account  of  the  symptoms,  which 
we  now  recognise  as  so  characteristic  of  duodenal  ulcer, 
was  given  in  a  paper  published  in  the  "Lancet,"  1905, 
i,  340.  Little  by  little  our  knowledge  of  this  group  of 
symptoms  had  been  growing,  but  it  was  not  until  that 
date  that  it  had  at  last  become  quite  clear.  Since  that 
paper  was  written  it  has  by  degrees  become  very  gener- 
ally acknowledged  that  duodenal  ulcer  is  a  far  more 
common  disease  than  was  formerly  believed,  and  that 
by  rigid  attention  to  the  details  of  the  clinical  history 
an  accurate  recognition  of  the  presence  of  the  ulcer  is 
not  beset  with  many  difficulties. 

Among  the  most  notable  contributions  to  this  sub- 
ject are  the  various  papers  of  W.  J.  Mayo  (see  especially 


History  23 

"Brit.  Med.  Jour.,"  1906,  ii,  1299,  and  "Jour.  Amer. 
Med.  Assoc,"  1908,  ii,  556),  and  of  Codman  ("Boston 
Med.  and  Surg.  Jour.,"  1909,  clxi,  313  and  767). 

Krauss  states  (p.  67)  that  the  first  occasion  on  which  a 
diagnosis  of  duodenal  ulcer  was  made  and  verified  is 
related  by  Wunderlich  ("Handbuch  der  Path,  und 
Therap.,"  iii,  175).  The  following  are  the  notes  of  the 
case: 

Perforated  duodenal  ulcer.  Abscess  cavity  between  pan- 
creas and  duodenum. — Man,  fifty-one,  not  strong,  began  in 
1845  to  have  pain  between  right  hypochondrium  and  epi- 
gastrium, which  radiated  over  the  whole  abdomen.  Pain 
came  on  in  attacks  three  to  four  hours  after  meals,  and  lasted 
a  few  hours  until  vomiting  of  undigested  food  occurred.  Six 
months  after  this  he  vomited  a  large  quantity  of  dark,  foul- 
smelling  blood;  pains  ceased  then  for  a  time,  but  returned 
after  a  year  or  so.  Vomiting  occurred  from  time  to  time  and 
there  was  a  tendency  to  constipation. 

In  1852  pain  and  vomiting  worse,  rapid  emaciation,  death. 

On  section:  Stomach  enormously  distended  and  displaced 
downwards;  pylorus  and  duodenum  were  firmly  adherent  to 
the  enlarged  head  of  the  pancreas  by  dense  connective  tissue. 
At  the  commencement  of  the  duodenum  was  a  circular  per- 
foration of  the  size  of  a  Groschen,  with  callous  margins.  This 
led  into  a  cavity  of  the  size  of  half  a  walnut,  whose  base  was 
formed  by  the  pancreas. 


CHAPTER  II 

ULCERATION  OF  THE  DUODENUM  IN  CASES  OF 
BURNS  OR  SCALDS 

In  a  paper  which  has  since  become  classical  Curling 
(" Med.-Chir.  Trans.,"  1841-42,  xxv,  260)  called  atten- 
tion to  the  connexion  between  cases  of  burn  or  of  scald 


Fig.  1. — Duodenal  Ulcer  Due  to  Burns. 
Parts  of  a  stomach  and  duodenum  exhibiting  an  ulcer  of  the  duodenum 
which  presents  the  characters  of  the  perforating  ulcer  of  the  stomach 
It  is  of  nearly  circular  form,  has  abrupt  margins,  and  is  an  inch  in  diameter. 
It  has  extended  through  all  the  coats  of  the  intestine  and  exposed  the  pan- 
creas, the  surface  of  which  now  forms  its  base.  The  nearest  margin  of  the 
ulcer  is  one-third  of  an  inch  from  the  pylorus.     A  bristle  is  placed  in  an 

24 


Ulceration  of  Duodenum  in  Burns  or  Scalds     25 

and  acute  ulceration  of  the  duodenum.  The  term 
"Curling's  ulcer'"  has  now  obtained  universal  currency, 
and  no  account  of  duodenal  ulcer  has  been  written  in 
recent  years  without  conspicuous  mention  being  made 
of  the  association  of  this  lesion  with  burns  or  scalds. 
Curling  himself  quotes  Dupuytren  ("Lecons  orales," 
Brussels  edition,  1836,  i,  217,  218)  as  having  drawn 
attention  to  the  congestion  of  various  mucous  membranes 
in  the  alimentary  canal  and  to  a  similar  condition  of  the 
blood-vessels  in  the  brain  and  lungs  in  the  early  stages 
of  burns;  and  to  the  occurrence  of  inflammation  of  the 
stomach  and  intestines  after  the  patient  had  recovered 
from  the  immediate  effects  of  the  injury. 

"Si  les  sujets  apres  avoir  resiste  a  la  premiere  impression 
flu  feu,  succombent,  du  trois  ieme  au  huitieme  jour,  a  la 
seconde  periode,  a  la  violence  de  la  reaction  inflammatoire, 
apr£s   avoir    presente   pendant   la   vie   tous   les   ph£nom&nes 

artery  in  the  pancreas,  which  was  opened  in  the  progress  of  the  ulcer  and 
permitted  fatal  haemorrhage. 

The  patient,  a  girl  aged  fifteen,  was  admitted  into  i  lie  London  Hospital, 
March  16,  1844,  on  account  of  a  burn,  which  extended  over  the  front  of  tin- 
chest,  left  upper  extremity,  neck,  and  upper  part  of  the  hack,  partially 
destroying  the  true  skin.  The  injury  was  not  followed  l>y  much  collapse, 
but  on  the  following  day  she  had  an  attack  of  fever,  which  continued  for 
four  or  five  days.  On  the  2lst  she  became  very  weak  and  complained  of 
pain  from  the  burn,  for  which  opium,  ammonia,  and  wine  were  administered. 
The  following  day  she  felt  better,  hut  from  that  period  till  her  death  she 
complained  at  intervals  of  pain  in  the  epigastric  region.  <  >n  the  30th  she 
vomited  a  large  quantity  of  dark,  tar-like  fluid.  From  this  time  she  sank 
rapidly,  and  expired  aboul  twelve  hours  afterwards,  having  passed  in  the 
course  of  the  day  dark  matter  by  stool.  On  examination  of  the  bodj 
(besides  what  is  shewn  in  the  preparation)  the  heart  was  found  flabby, 
with  only  a  small  quantity  of  blood  in  its  cavities.  The  stomach  contained 
a  quantity  of  dark  fluid,  resembling  thai  vomited  during  life,  and  in  the 
intestines  there  w.i^  dark,  pitchy-looking  matter.  ;S<  e  "Lancet,"  June 
14.  1.H44,  p.  387.  Presented  by  T.  Blizard  Curling,  Esq.  Royal  College 
oi  Surge*  ma  \l  useum,  No.  24 


26 


Duodenal  Ulcer 


d'une  vive  irritation  des  visceres,  on  trouve  a  I'ouverture  des 
cadavres,  tous  les  signs  de  la  gastro-enterite  la  mieux  carac- 
terisee,  el   ordinairemenl    accompagnee  d'alterations  inflam- 


Fig.  2. — Duodenal  Ulcer  Due  to  Burns. 

The  pyloric  portion  of  a  stomach  and  part  of  the  duodenum.  In  the 
latter  are  two  ulcers,  the  larger  immediately  beyond  the  valve,  the  other 
an  inch  and  a  half  beyond  it.  The  floor  of  the  larger  ulcer  is  deeply  placed 
and  very  thin,  being  formed  of  peritoneum  alone;  but  the  edges  are  round, 
as  if  healing  had  commenced.      In  the  lower  ulcer  this  is  even  more  marked. 

From  a  boy  aged  seven,  who  was  extensively  burnt  on  the  front  and  back 
of  the  body.  In  front  the  skin  and  subcutaneous  tissue  were  destroyed 
from  a  little  above  the  clavicles  to  within  three  inches  of  the  pubes,  so  that 
when  the  slough  separated  the  muscles  were  laid  bare.  The  back  was 
affected  to  a  similar  extent,  though  less  deeply.  He  died  four  weeks  after 
the  injury.  He  had  suffered  during  his  life  from  no  intestinal  symptoms. 
(Royal  College  of  Surgeons  Museum,  No.  2431.  Presented  by  Thomas 
Blizard  Curling.) 

matoires  de  I'encephale  e1  des  poumons Enfin  si  le 

sujet  n'a  succombe  qu'a  une  epoque  beaucoup  plus  eloignee, 
pendant  le  cours  de  la  periode  de  suppuration  el  d'epuise- 


Ulceration  of  Duodenum  in  Burns  or  Scalds     27 

ment.  on  trouve  dans  les  visceres,  et  surtout  dans  le  canal 
digestif,  des  alterations  profondes  qui  attestent  la  longue 
inflammation  dont  ils  one  ete  effectes;  la  muqueuse  est 
parsemee  de  plaques  d'un  rouge  plus  ou  moins  vif,  ou  plus 
011  moins  fonc6,  d'ulcerations  plus  ou  moins  profondes;  les 
ganglions  mesenteriques  sont  generalement  engorges,"  etc. 


Fig.  3. — Duodenal  Ulcer  Due  to  Burns. 

A  duodenum,  showing  an  ulcer  an  inch  and  a  half  beyond  the  pylorus, 
laying  open  the  arteria  pancreatico-duodenalis.  It  isof  oblong  shape,  with 
thick,  rather  undermined  edges  and  smooth  floor.  The  whole  thickness 
of  the  bowel  is  destroyed  and  a  rent  has  taken  place  into  the  peritoneal 
cavity  close  to  the  margin  of  the  ulcer. 

From  a  ^irl ,  aged  seven,  who  was  severely  burnl  over  the  greater  part 
of  the  abdomen  and  the  left  thigh.  Death  took  place  eighl  days  after, 
with  haemorrhage  of  the  bowel.  (See  "Lancet."  [866,  vol.  i.  p.  484. 
Royal  College  of  Surgeons  Museum,  No.  2430.  Presented  bj  Thos. 
Blizard  ( )urling,  Esq. 

The  first  writer  to  note  and  to  describe  with  lull 
knowledge  the  occurrence  of  duodenal  ulcer  in  cases  <>| 
burn  was  neither  Curling  nor  Dupuytren,  bul  James 
l.«»ng.  of  Liverpool  ("London  Medical  Gazette,"  [840, 
new  series  i,  743).     He  relates  the  following  two  ca 


28 


Duodenal  Ulcer 


Case  i.  Ann  Jones,  aet.  twenty-eight,  admitted  into  the 
Infirmary  on  the  2d  of  April,  1834,  with  an  extensive  and 
deep  burn  of   the  arms,   chest,   and   nates.     She  states  that 


Fig.  4. — Duodenitis  Following  Burns. 

In  the  duodenum  immediately  beyond  the  pylorus  are  two  clusters  of 
enlarged  Brunner's  glands  with  evidently  patulous  orifices.  The  fresh 
appearances  wen-  those  of  recent  inflammation  and  superficial  ulceration 
of  the  mucous  membranes  covering  the  glands. 

From  a  girl,  aged  six  and  a  half  years,  who  was  admitted  with  extensive 
burns  over  the  surface  of  the  body  and  extremities,  and  who  died  on  the 
ninth  day  from  pneumonia;  for  the  first  three  days  vomiting  was  a  prom- 
inent symptom.     'St.  Thomas's  Hospital  Museum,  No.  1066.) 


she  was  in  perfect  health  previous  to  the  accident ;  she  vomited 
more  or  les>  every  day,  sometimes  excessively;  had  consider- 
able pain  on   pressure  in   the  epigastric  region,  with  a  red, 


Ulceration  of  Duodenum  in  Burns  or  Scalds     29 

glassy  tongue  and  intense  thirst;  bowels  constipated  and  re- 
lieved by  enemata;  the  pulse  for  some  days  was  small  and 
weak,  then  full  and  strong;  died  on  the  eighth  day  after  the 
accident. 

Postmortem  examination:  Xo  peritoneal  inflammation; 
stomach  contracted;  mucous  membrane  white,  firm,  not  a 
vessel  to  be  seen  upon  it;  pylorus  healthy;  at  the  superior 
angle  of  the  duodenum  a  perforation  or  ulceration  existed  of 
the  size  of  a  shilling;  the  margins  of  the  perforation  were 
adherent  to  the  gall-bladder,  but  the  slightest  traction  sepa- 
rated them;  the  surface  of  the  gall-bladder  filled  up  the  area 
of  the  perforation,  soft  and,  as  it  were,  eroded,  the  softened 
surface  being  easily  scraped  off;  the  edges  of  the  perforation 
and  the  corresponding  surface  of  the  gall-bladder  were  of  a 
black  colour;  two  or  three  ulcers  of  the  size  of  a  pea  and  with 
dark  edges  were  also  found  in  the  duodenum,  and  the  remain- 
der of  the  intestinal  mucous  membrane  ,was  quite  healthy, 
excepting  two  small  red  patches  in  the  sigmoid  flexure  of  the 
colon,  which  corresponded  to  two  masses  of  hardened  faeces. 

CASE  2. — Helena  Birch,  a?t.  fourteen,  admitted  May  24, 
1834,  with  a  burn  of  the  second  degree,  of  the  nates,  posterior 
part  of  the  neck,  and  both  arms;  she  was  in  perfect  health 
prior  to  the  accident.  She  complained  of  nothing  except 
pain  in  the  burned  parts,  until  the  tenth  day  after  the  acci- 
dent. At  this  period  pain  in  the  epigastric  region  com- 
menced; at  the  same  time  the  hypogastric  region  became  the 
seat  of  pain;  the  tongue  was  but  slightly  altered;  she  had 
no  vomiting;  and  the  pulse  was  -mall  and  quick.  On  the 
eleventh  day  the  symptoms  were  more  severe;  on  the  morn- 
ing of  the  twelfth  the  pain  in  the  epigastric  region  became 
intense;  very  shortly  afterwards  she  was  seized  with  vomit- 
ing and  profuse  diarrhoea,  sudden  distension  of  the  abdomen, 
prostration  of  strength,  and  in  eleven  hours  she  died.  There 
was  no  doubt  that  perforation  had  taken  place  in  some  parts 
of  the  gastro-mtestinal  tube;  note,  she  always  lay  upon  the 
abdomen. 

Postmortem  examination:  Peritoneal  lining  <>i  abdominal 
muscles,  and  it-  reflections  over  the  liver,  uterus,  and  intes 
tine,   wen-  (Mated   with  custard-like  coagulated   lymph;    the 


^o  Duodenal  Ulcer 

omentum  was  in  a  similar  state,  and  there  was  about  two 
pints  of  whey-like  fluid  floating  in  the  cavity  of  the  abdomen; 
the  peritoneal  coat  of  the  intestines  was  intensely  red;  the 
mucous  lining  of  the  stomach,  jejunum,  and  ileum  was  quite 
healthy;  a  few  red  patches  were  visible  in  the  colon;  the 
duodenum  at  its  superior  angle  presented  a  perforation  the 
size  of  a  shilling. 

The  state  of  the  duodenum  and  of  the  perforation  in  this 
case  differed  from  the  preceding  one  only  in  the  following 
particulars:  the  perforation  was  rather  nearer  to  the  pylorus, 
its  margins  were  not  black,  it  did  not  adhere  to  the  gall- 
bladder, and  there  were  no  ulcerations. 


Long  adds:  "  I  have  been  induced  to  give  the  two 
cases  of  perforation  of  the  duodenum  in  detail,  as  I 
believe  they  are  unique;  indeed,  I  am  not  aware  of  any 
case  being  recorded  of  perforation  of  the  gastro-intestinal 
tube  occurring  after  a  burn,  except  the  one  I  quote  from 
Liston,  which  approximates  to  my  two  cases  by  the 
perforation  being  near  the  pylorus,  and  by  the  change 
which  had  taken  place  in  the  duodenum." 

He  quotes  the  following  case,  recorded  by  Liston : 


Female  child,  set.  three,  on  the  4th  of  May  received  a 
severe  burn  of  the  upper  part  of  the  abdomen,  lower  part 
of  the  chest,  arms,  and  occiput;  on  the  seventh  day  vomited 
blood,  and  died.  Lymph  in  flakes,  slightly  gluing  the  intes- 
tines together;  purulent  yellowish  fluid  in  the  cavity  of  the 
abdomen;  grumous  blood  with  lymph  lying  at  the  lower 
border  of  the  stomach;  two  ounces  of  grumous  blood  in  the 
stomach;  perforation  in  stomach  beyond  the  pylorus;  the 
edges  of  the  perforation  elevated;  some  enlarged  glands  in  the 
external  coat  of  the  stomach,  near  the  perforation.  The 
coats  of  the  duodenum  also,  near  the  ulcer,  were  thickened 
and  elevated,  with  spots  of  yellow  hue. 


Ulceration  of  Duodenum  in  Burns  or  Scalds     31 

This  remarkable  paper  has  been  overlooked  by  every 
subsequent  writer;  its  perusal  leaves  no  doubt  that  the 
credit  for  priority  in  this  matter  is  due  entirely  to  Long. 

Nearly  all  the  large  museums  in  London  now  contain 
specimens  showing  "Curling's  ulcers,"  and  the  impres- 


Fig.  5.— Duodenal  Ulcer  Due  ro  Burns. 

There  are  two  oval  ulcers  about  half  an  inch  in  diameter,  and  main  of 
smaller  size.  In  t he-  mucous  membrane  oi  the  duodenum  the  two  large 
ulcers  have  extended  beyond  the  mucous  membrane  and  penetrated  all  the 
coatsofthc  intestine.  One  of  thorn  i-  closed  by  a  continuous  adherenl 
surface  of  the  pancreas;   the  other  opened  into  the  cavity  of  the  abdomen. 

From  a  child  aboul  two  years  of  age,  who  died  suddenly  during  the 
progress  of  recovery  from  a  burn.     (St.  Barth.  Il<»|>.  Museum,  No.  [91 

sion  seems  to  prevail  thai  this  morbid  condition  is  one 
o\  some  frequency,  and  that  this  type  ol  ulcer  includes 
a  notable  proportion  of  the  whole  number  ot  ulcers 
which  affect  the  duodenum.  1  believe,  however,  thai  the 
lesion    is   an    extremely    infrequenl    one,    for   in    nearly 


32  Duodenal  Ulcer 

twenty  years  not  one  single  case  has  been  observed  in 
the  post-mortem  room  of  my  own  hospital  wherein 
cases  of  burn  are  frequently  admitted.  In  my  own 
scries  of  cases  treated  by  operation  it  is  the  fact  that 
no  case  has  been  met  with  in  which  a  burn  could  be  in 


Fig.  6. — Ulcer  of  the  Duodenum  Following  a  Burn. 

The  pyloric  end  of  a  stomach  with  the  first  part  of  the  duodenum. 
Just  beyond  the  pyloric  ring  there  is  a  round,  punched-out  ulcer  about  a 
quarter  of  an  inch  in  diameter,  in  the  base  of  which  is  exposed  the  muscular 
coat  of  the  intestine. 

Marian  C,  set.  thirteen,  was  admitted  under  Mr.  Durham  for  severe 
burns  of  the  trunk.  She  died  from  tetanus  about  a  fortnight  after  the 
accident.  At  the  autopsy  the  skin  over  the  injured  parts  was  sloughing. 
(Guy's  Hosp.  Museum,  No.  741.) 


any  degree  held  responsible  for  the  appearance  of  the 
ulcer,  nor  indeed  has  any  noteworthy  scar  of  a  burn  or 
scald  ever  been  found  upon  the  surface  of  the  bodies  of 
patients  who  were  treated  for  this  disease.  The  cases 
of  chronic  ulcer  of  the  duodenum  which  have  a  clinical 


Ulceration  of  Duodenum  in  Burns  or  Scalds     33 

significance  do  not  seem,  therefore,  to  be  in  any  way 
dependent  upon  these  injuries. 


c 


Fig.  7. — Duodenal  (Jlcer  Following  Burns. 

Portion  of  the  pyloric  end  of  a  stomach  along  with  the  duodenum  shew- 
ing an  extensive  ulcer  in  the  first  portion  of  the  latter,  following  a  burn. 
The  inner  aspect  of  the  latter  is  very  large,  and  of  the  size  of  a  bean;  and 
at  its  upper  part  is  a  small  aperture  through  the  muscular  and  peritoneal 
coats,  which  existed  during  life.  The  posterior  part  of  the  ulcer  has  been 
greatly  strengthened  by  masses  of  fibrin  which  have  been  accumulated. 
The  duodenum  contained  a  large  clot  of  blood,  about  six  inches  long, 
moulded  upon  its  walls;  no  other  part  of  the  intestines  was  ulcerated,  but 
they  were  highly  congested. 

The   patient,   Sarah   T ,   aged    nineteen,   was  admitted    April  Qth, 

with  extensive  and  painful  burns  about  the  thighs  and  shoulders.  She 
died  April  IQth,  ten  days  after  admission,  and  before  death  the  bowels, 
winch  had  been  confined  for  some  days  alter  the  accident,  became  much 
relaxed  and  the  faeces  contained  blood.  On  the  day  before  her  death  she 
vomited  much  matter  mixed  with  blood.  (St.  George's  Hosp.  Museum, 
No.  90  A.) 

It  is  perhaps  owing  to  the  interesting  and  obscure 
nature  <>f  these  cases  thai   unusual  attention  has  been 

3 


34 


Duodenal  Ulcer 


paid  to  them,  and  the  impression  as  to  their  frequency 
has  unconsciously  become  exaggerated.  It  is  a  fact, 
however,  that  acute  ulceration  of  the  duodenum  does 
occur  in  cases  of  burn  or  scald;    and  that  the  surface 


Fig.  8. — Ulcer  of  the  Duodenum  Following  a  Burn. 

The  first  part  of  the  duodenum,  shewing  a  clean-cut  oval  opening  in  its 
posterior  wall,  the  upper  limit  of  which  is  about  half  an  inch  from  the 
pylorus.  The  ulcer  is  one  and  a  half  inches  long,  and  in  the  recent  state 
its  base  was  formed  by  the  pancreas,  which  was  eroded.  The  ulcerative 
process  had  exposed  and  opened  the  superior  pancreatico-duodenal  artery. 

Herbert  E.,  set.  four,  was  admitted  under  Mr.  Durham  for  several 
burns  upon  the  lower  extremities  and  buttocks.  The  child  did  well  for 
sixteen  days,  after  which  he  began  to  pass  blood  with  his  motions.  The 
haemorrhage  proved  fatal  on  the  nineteenth  day  after  the  accident.  At  the 
autopsy  the  intestines  were  found  to  contain  much  black  blood.  (Guy's 
Hosp.  Museum,  No.  740.) 

lesion  does  bear  a  definite  causal  relationship  to  the 
lesion  of  the  mucosa  of  the  alimentary  canal,  especially 
of  the  duodenum. 

In  his  original  paper  Curling  gave  detailed  notes  of 
12    cases,    and    subsequently    recorded    another    case. 


Ulceration  of  Duodenum  in  Burns  or  Scalds     35 

Erichsen  ("London  Medical  Gazette,"  1843,  xxxi,  544), 
in  a  study  of  the  pathology  of  burns,  cites  3  cases  of 
ulcer  of  the  first  portion  of  the  duodenum  occurring 
on  the  fourth,  seventh,  and  eighth  days  after  the  acci- 
dent. Wilks  ("Guy's  Hosp.  Rep.,"  1856,  3d  scries. 
ii,  133),  in  a  short  paper,  reviewed  the  12  fatal  cases 
surviving  four  days  or  over  occurring  within  a  period 
of  eighteen  months  in  Guy's  Hospital.  In  every  instance 
the  duodenum  was  absolutely  healthy.  Confirmatory 
evidence  of  the  accuracy  of  Curling's  observations  was 
given  by  Timothy  Holmes  ("System  of  Surgery,"  i860, 
i,  738),  Ponfick  ("Berl.  klin.  Woch.,"  1876,  i,  225),  \V. 
Stokes  ("Dublin  Jour.  Med.  Sci.,"  1876,  lxii,  327),  and 
others,  and  there  is  no  longer  any  doubt  as  to  the  strict 
dependence  of  acute  ulceration  in  the  duodenum  upon 
the  destructive  lesions  of  the  skin  produced  by  burns 
or  scalds.     On  this  point  Perry  and  Shaw  write: 

"Although  the  investigation  of  all  the  cases  of  burn 
examined  in  the  post-mortem  room  at  Guy's  shews  a 
smaller  percentage  of  duodenal  ulcers  than  has  been 
found  in  the  less  extended  series  of  cases  compiled  at 
other  institutions,  we  must,  having  regard  to  the  extreme 
rarity  of  ulceration  from  all  causes  in  this  part  of  the 
alimentary  canal,  admit  an  undoubted  relationship 
between  the  cutaneous  and  intestinal  lesion.  Our  own 
statistics  indicate  that  whilst  of  persons  dying  from  all 
causes  0.4  per  cent,  only  are  found  with  duodenal  ulcera- 
tion, no  less  than  3.3  per  cent,  oi  those  dying  from 
burn-  exhibit   this  condition." 

The  nature  of  the  relationship  between  these  two 
conditions  ha-  formed   the  subjecl  of  much  interesting 


36  Duodenal   Ulcer 

speculation.  Curling  in  a  foot-note  (lor.  cit.,  p.  277) 
states  that  he  received  from  Bowman  the  hint  that  the 
glands  of  Brunner  were  the  probable  seat  of  ulceration. 
No  evidence  was  then  given,  nor  has  any  been  since  put 
forward  to  support  this  view;  the  supposed  "sympathy" 
between  these  glands  and  the  burnt  skin,  which  has  been 
suggested  by  Brown-Sequard  and  Handheld-Jones,  is,  as 
Perry  and  Shaw  truthfully  say,  "entirely  unsupported 
by  any  physiological  or  pathological  evidence."  W. 
Hunter  ("Path.  Soc.  Trans.,"  1890,  xli,  105)  suggested 
that  the  inflammation  of  the  duodenum  and  the  con- 
secutive ulceration  were  due  to  the  excretion  of  some 
irritant  products  through  the  bile.  He  found  that 
after  subcutaneous  injections  of  toluylenediamine  in 
dogs  intense  jaundice  was  produced;  when  the  animals 
were  killed  three  to  seven  days  later  certain  changes 
were  found  in  the  duodenum.  The  duodenum,  even 
before  being  opened,  was  obviously  inflamed,  and 
its  turgid,  swollen  walls  felt  "doughy."  On  being 
opened  the  most  intense  inflammatory  congestion  of 
the  mucous  and  submucous  coats  was  seen,  and  the 
lumen  of  the  canal  was  filled  with  a  large  quantity  of 
clear  inflammatory  mucus.  In  other  cases  ulcers  were 
found.  The  changes  were  most  marked  in  the  neigh- 
bourhood of  the  bile  papilla.  Occasionally  other  parts 
of  the  small  intestine  were  affected,  especially  the 
terminal  portion  of  the  ileum.  The  appearances  pointed 
to  the  action  of  a  powerful  irritant,  the  only  channel  of 
whose  excretion  was  the  bile.  The  close  similarity 
between  ulceration  of  the  duodenum  in  cases  of  burns 
and  that  experimentally  produced  is  evident.     Hunter 


Ulceration  of  Duodenum  in  Burns  or  Scalds     37 

accordingly  suggested  that  the  factor  common  to  both 
was  the  presence  of  a  poison  due  to  some  destructive 
process  occurring  in  the  blood,  and  the  discharge  of  this 
poison  in  the  bile.  Marked  changes  in  the  blood, 
occurring  after  burns,  have  been  described  by  Lesser 
(quoted  by  Hunter,  p.  m),  and  Ponfick  and  others 
have  shewn  that  extensive  scalds  will  produce,  in  ani- 
mals, haemolysis  similar  to  that  seen  after  the  injection 
of  toluylenediamine.  Fenwick  ("Jour,  of  Pathology," 
1893,  i,  417)  found,  however,  that  in  dogs,  after  ligation 
of  the  common  bile-duct,  ulceration  of  the  duodenum 
still  followed  the  injection  of  this  drug.  It  is  therefore 
clear  that  for  the  present,  and  until  clearer  evidence-  is 
forthcoming,  we  must  suspend  our  judgment  in  this 
matter. 

This  hypothesis,  moreover,  leaves  untouched  the 
undoubted  fact  that  the  ulceration  is  far  more  frequently 
met  with  above  the  biliary  papilla  than  in  the  immediate 
vicinity  of  that  point.  Gandy  in  his  thesis  ("These  de 
Paris,"  1899)  has  shewn  conclusively  that,  as  many 
observers  have  individually  recorded,  congestion  and 
hemorrhagic  erosion,  the  common  precursors  of  toxic 
ulceration  in  mucous  membranes,  occur  elsewhere  in 
the  alimentary  canal.  It  is  only  necessary,  therefore, 
to  detect  some  special  feature,  limited  to  the  first  part 
of  the  duodenum,  which  shall  account  tor  the  disposition 
there  shewn  for  the  slightest  lesion  to  be  converted  into 
an  ulcerative  process.  This  special  circumstance  surel) 
is  the  forcible  injection  of  the  acid  chyme  through  the 
pylorus.  The  chyme  impinges  upon  the  duodenal  wall 
at  that  part  where  ulceration  i>  mosl  commonly  found; 


38  Duodenal  Ulcer 

in  addition  to  this  mechanical  assault  or  irritation, 
there  is  the  possibly  more  potent  action  of  the  gastrie 
juice  as  a  chemical  agent,  digesting  the  already  damaged 
portion  of  the  intestinal  wall. 

Duodenal  ulcer  in  connexion  with  burns  is  doubtless 
a  toxic  ulcer,  and  therefore  analogous  to  the  ulcer  which 
occurs  in  septicaemia,  uraemia,  typhoid  fever,  erysipelas, 
and  pemphigus.  It  is  almost  without  exception  the 
rule  to  find  the  ulcer  only  in  cases  where  septic  processes 
in  the  burnt  skin  have  developed;  and  the  frequency  of 
duodenal  ulcer  in  cases  of  burn  or  scald  may  well  be  due 
to  the  special  liability  to  suppuration  and  to  sloughing 
which  these  injuries  display.  A  point  which  requires 
investigation  in  this  connexion  concerns  the  presence 
and  possible  influence  of  septic  emboli,  conveyed  from 
the  infected  area  to  different  regions  in  the  body.  In 
the  alimentary  canal  they  would  produce  haemorrhagic 
infiltration,  which,  immediately  beyond  the  pylorus, 
would  readily  be  converted  into  ulcers  by  the  action  of 
the  gastric  juice. 

In  recent  years  in  many  hospitals  a  special  search  for 
duodenal  ulcer  in  patients  who  have  died  of  burns  has 
been  made  by  the  most  competent  investigators.  It 
is  a  matter  of  common  agreement  that  this  lesion  is 
rarely  found,  and  this  may  well  be  due  to  the  less 
septic  condition  in  which  their  cases  are  kept  nowadays. 

POSITION  AND  CHARACTER  OF  THE  ULCER 
Both    the    ulcer,    and    the    lesion    which    precedes    it, 
whether  congestion,  ecchymosis,  or  haemorrhagic  erosion, 
may  be  solitary  or  multiple.     As  they  affect  the  duode- 


Ulceration  of  Duodenum  in  Burns  or  Scalds     39 

num  they  are  only  a  part,  though  doubtless  the  most 
conspicuous  part,  of  a   process   precisely   similar  which 


Fig.  9. — Duodenal  Ulcer  and  Gastrk    1  lcef  Due  to  Burns. 

The  pyloric  end  of  the  stomach,  the  pylorus  and  pari  of  the  duodenum 
laid  open,  shewing  ulceration  of  the  latter.  Aboul  one-half  inch  beyond 
the  pylorus  there  i-  an  ulcer  in  the  mucous  membrane  aboul  the  size  of  a 
sixpence,  but  somewhat  irregular  in  shape.  It  looks  as  il  .1  slough  had 
recently  separated,  and  the  edges,  «  hi<  h  are  broken  off,  appear  to  be  already 
cicatrising.  In  the  mucous  membrane  of  the  stomach, about  one  and  a  half 
inches  above  the  pylorus,  tin-re  is  a  small  oval  superficial  ulcer,  which  is 

abruptly  defined. 

From  a  woman,  aged  seventy,  who  died  on  the  tenth  day  from  hums. 
(London  I  Iospii.il  Museum.  No.  it);. 

affects,  or  may  affect,  other  parts   of   the   alimentary 
canal.     Holmes    ("System    of   Surgery,"    [86o,   i,   7  vs 


40  Duodenal  Ulcer 

and  P.  Laure  ("Diet,  encyclop.  des  Sciences  Medicales," 
1887,  xxxiv,  603)  record  cases  where  ulceration  in  the 
jejunum  and  at  the  termination  of  the  ileum  was  found. 
Ponfick  ("Berl.  klin.  Woch.,"  1877,  xiv,  47)  relates  one 
case  where  hemorrhagic  erosion  and  superficial  ulcera- 
tion were  present  in  the  first  part  of  the  duodenum 
eighteen  hours  after  the  accident.  In  three-fourths  of 
the  cases  the  ulceration  is  found  exclusively  in  the  first 
part  of  the  duodenum;  in  the  remainder  it  is  in  the  first 
and  second,  or  the  second  parts.  It  is  very  rarely  seen 
below  the  ampulla  of  Yater.  In  the  29  cases  of  Perry 
and  Shaw  the  ulcer  was  single  in  16  cases;  in  12  there 
were  two  or  more  ulcers;  in  one  information  is  lacking. 
The  ulcer  may  be  superficial,  being  a  mere  surface 
denudation  of  epithelium;  more  often  it  is  deep,  and 
appears  as  though  a  slough  had  separated  from  it.  It 
may  be  circular,  oval,  or  irregular;  may  be  a  mere  loss 
of  tissue  or  may,  in  rare  cases,  shew  definite  evidence 
of  attempted  repair.  This  form  of  ulcer  is  found  in 
patients  of  all  ages.  The  youngest  patient  whose  his- 
tory is  recorded  was  a  child  of  twelve  months,  who  died 
on  the  twentieth  day  after  being  scalded  extensively  on 
the  chest.  Acute  inflammation  and  ulceration  were 
found  in  the  duodenum  (St.  Bart.'s  Hosp.  Museum, 
1969a).  The  oldest  patient  was  a  woman,  seventy 
years  of  age,  who  died  on  the  tenth  day  after  being 
burnt.  A  small  ulcer  was  found  in  the  stomach,  a 
large  one  in  the  duodenum  (London  Hosp.  Museum, 
1  [43).  A  specimen  from  a  woman  of  sixty-six,  who 
died  on  the  seventeenth  day,  is  in  St.  George's  Hospital 
Museum  (No.  90b). 


Ulceration  of  Duodenum  in  Burns  or  Scalds     41 

SYMPTOMS 
Clinically  the  ulcer,  which  occurs  twice  as  frequently 
in  females  as  in  males,  may  assert  itself  with  a  great 


Fig.  [o.  —Duodenal  Ulcer  Following  Burns. 

Portion  of  the  stomach  and  duodenum  shewing  a  large  oval  ulcer  in  the 
latter  immediately  below  the  pylorus.  Removed  from  the  body  of  a  pa- 
tient who  was  extensively  burnt  over  the  lace,  neck,  and  upper  extremities. 
The  ulcer  is  about  one  and  one-half  inches  long  and  one-half  inch  in  breadth 
and  situated  immediately  beyond  the  pylorus.  The  muscular  part  of  the 
walls  is  almost  equally  destroyed  with  the  mucous  part,  and  a  branch  of  the 
pancreatico-duodenal  artery  is  cntireb  laid  open.  The  margins  of  tin' 
ulcers  are  rounded  and  swollen  and  are  moderately  muscular,  its  base  being 
formed  by  tin'  Opposed  pancreas.  Below  this  larger  patch  of  ulceration 
a  smaller  one  also  existed,  and  the  neighbouring  solitary  glands  are  much 
enlarged.  The  enl  in-  intestinal  t  rad  ,  as  low  down  as  t  In-  lower  pari  of  the 
colon,  contained  a  reddish  and  black  fluid  composed  of  faecal  matter  and 
coagulated  blood. 

The  patient,  Elizabeth  J  -,  set.  five,  was  admitted  on  Maj  4.  [850. 
uffered  in  mi  pain  in  t  he  abdomen,  but  noi  from  vomiting  and  purging, 
and  sank  from  collapse  May  9th.  (For  details  see  Post-mortem  and  Case 
Books,  1850,  p.  82.     St.  George's  Hosp.  Museum,  No.  90  (  , 

variety  of  manner.  In  no  small  proportion  of  the  cases 
the  ulcer  has  been  latent,  producing  no  symptoms,  and 
giving  no  hint   of  ii^  presence,   during   the  life  of   the 


42  Duodenal  Ulcer 

patient.  At  the  post-mortem  examination  one  or  two 
ulcers  may  be  found,  and  the  process  of  healing  in  some 
may  be  beginning,  or  may  even  be  complete.  In  the 
majority  of  the  cases  either  perforation  or  haemorrhage 
or  both  are  the  first  warnings  given.  In  20  of  the  29 
cases  followed  by  Perry  and  Shaw  one  or  both  occurred. 
The  case  of  earliest  perforation  is  recorded  by  W.  C. 
Hills  ("Jour,  of  Mental  Sci.,"  1881,  xxvi,  556);  the 
patient  was  a  girl  of  eighteen  who  was  accidentally 
scalded  to  the  second  degree  by  hot  water.  Vomiting 
occurred  the  next  day,  and  eighty-three  hours  later  she 
died  collapsed.  At  the  autopsy  an  ulcer  the  size  of  a 
shilling  was  found  on  the  posterior  wall  of  the  duodenum 
two  inches  from  the  pylorus.  The  ulcer  involved  all  the 
coats  of  the  duodenum,  was  in  part  adherent  to  the 
pancreas,  and  perforation  into  the  general  peritoneal 
cavity  had  occurred.  A  case  of  a  death  .from  haemor- 
rhage, the  pancreatico-duodenal  artery  being  opened, 
occurring  four  and  one-half  days  after  the  injury,  is 
recorded  by  Caesar  Hawkins  ("Path.  Soc.  Trans.," 
1 85 1,  ii,  290).  Perforation  may  occur  between  the  fifth 
and  the  twentieth  days,  and  is  most  common  on  the 
tenth  and  eleventh.  It  is  very  rarely  preceded  by 
symptoms,  and  ends  speedily  in  the  death  of  the  patient. 
There  is  no  recorded  case  of  surgical  treatment  being 
adopted,  but  there  is  no  reason  why  it  should  not  prove 
successful  if  the  condition  of  the  patient  were  not  too 
exhausted  by  the  extent  or  severity  of  the  original 
injury.  Haemorrhage  is  more  common  than  perforation; 
in  Perry  and  Shaw's  twenty  cases  there  were  7  of  perfor- 
ation and  13  of  haemorrhage.     It  is  sometimes  preceded 


Ulceration  of  Duodenum  in  Burns  or  Scalds     43 

by  a  sense  of  heat  in  the  epigastrium  or  by  collapse 
and  great  prostration.  It  has  proved  fatal  as  early  as 
four  and  one-half  days  and  as  late  as  thirty-seven  days 
after  the  accident;  the  day  of  maximum  frequency  is 
the  fifteenth.  In  the  ulcer  from  which  the  haemorrhage 
comes  no  vessels  may  be  seen  laid  open,  the  bleeding 
having  occurred  from  several  small  points,  or  rarely  a 
large  artery,  the  pancreatico-duodenal,  or  a  branch  of  it, 
may  have  its  walls  destroyed.  In  one  case  related  by 
Keate  ("Path.  Soc.  Trans.,"  1850,  i,  258)  the  patient,  a 
girl  of  six,  lived  seventy-five  days  after  being  severely 
burnt;  three  ulcers  were  found  in  the  duodenum.  This 
is  the  longest  period  of  survival  mentioned  in  any  of  the 
records. 


CHAPTER  III 

URJEMIC  ULCER  OF  THE  DUODENUM 

It  has  long  been  a  matter  of  common  knowledge 
that  superficial  erosions,  or  ulcerations,  are  found  in 
certain  parts  of  the  alimentary  canal  in  fatal  cases  of 
Bright's  disease.  The  regions  most  frequently  affected 
are  the  lower  portions  of  the  small  and  the  upper  por- 
tions of  the  large  intestines.  The  stomach  also  con- 
tains, not  rarely,  similar  evidences  of  superficial  ulcer- 
ations, more  especially  in  its  pyloric  portion.  The 
mouth  has  in  some  few  instances  shewn  multiple  points 
of  inflammation,  or  of  actual  destruction  of  the  mucous 
membrane,  as  Barie  ("Arch.  Gen.  de  Med.,"  1889,  ii, 
415),  and  later  Renon  ("Bull.  Soc.  Med.  des  Hopitaux," 
1898,  xv,  475)  and  Hirtz  ("Sem.  Med.,"  1902,  xxii, 
109),  have  shewn.  An  interesting  case  has  been  recorded 
by  Dalche  and  Claude  ("Bull,  et  Mem.  de  la  Soc.  Med. 
des  Hopitaux  de  Paris,"  1903,  xx,  75),  in  which  ulcer- 
ation of  the  skin,  of  the  mucous  membranes  of  the  mouth 
and  anus,  and  of  the  umbilicus  occurred  in  a  case  of 
Bright's  disease.  Haemorrhages  into  the  deeper  layer 
of  the  skin  and  of  the  mucous  membranes  preceded  the 
destruction  of  the  upper  layers;  petechial  haemorrhages 
led  rapidly  to  ulceration.  Mathieu  and  Roux  ("Arch. 
Gen.  de  Med.,"  1902,  clxxxix,  14)  record  one  case  in 
which  there  was  a  continuous  ulceration  over  a  length  of 

44 


Uraemic  Ulcer  of  the  Duodenum  45 

30  centimetres  in  the  ileum.  The  duodenum  also, 
though  more  rarely,  may  be  involved  in  a  process  of 
uraemic  ulceration,  as  was  pointed  out  by  Treitz  in 
1859  and  by  Wilks  and  Moxon  in  the  second  (1875) 
edition  (p.  405)  of  their  "Lectures  on  Pathological 
Anatomy."  Perry  and  Shaw  point  out  that  the  remark 
that  duodenal  ulcers,  like  gastric  ulcers,  "are  often 
associated  with  Bright's  disease,"  occurs  only  in  this 
edition,  and  it  is  not  to  be  found  in  either  the  first  or 
the  third.  As  the  second  edition  was  revised  by  Moxon, 
the  observation  doubtless  rests  upon  his  authority  alone. 
Most  of  our  knowledge  of  this  subject  is  due  to  the 
work  of  Perry  and  Shaw,  who  collected  from  the  post- 
mortem records  of  Guy's  Hospital,  and  from  the  litera- 
ture, a  series  of  cases  which  shewed  the  various  forms  of 
ulceration  which  might  involve  the  duodenum  in  patients 
affected  with  Bright's  disease.  Since  their  work  ap- 
peared, only  a  small  number  of  cases  have  been  recorded. 
The  most  noteworthy  contribution,  containing  a  record 
of  22  cases  of  "albuminuric  ulcers"  of  the  intestine,  was 
published  by  W.  H.  Dickinson  ("Med.-Chir.  Trans.." 
1894,  lxxvii,  iii).  G.  Lecointe  in  1903  devoted  a  Paris 
thesis  to  the  consideration  of  the  subject,  and  Baric- 
and  Delaunay  ("Bull,  et  Mem.  de  la  Soc.  Med.  des 
Hdpit.  de  Paris,"  1903,  xx,  45)  record  in  detail  an 
exemplary  instance  of  the  condition  and  briefly  review 
the  reported  cases.  An  interesting  paper  recording 
two  cases  of  multiple  intestinal  ulcers  in  eases  of  chronic 
nephritis  is  contributed  by  Maekey  ("Brit.  Med.  Jour.," 
1909,  i,  1002  . 
An    examination    of    all    cases    recorded    shews    that 


46 


Duodenal  Ulcer 


ulceration  in  the  duodenum  may  be  considered  in  some 
cases  as  dependent  upon  the  change,  usually  an  advanced 
change,  which  has  occurred  in  the  kidneys,  and  in  other 
cases  as  being  in  all  probability  in  no  direct  relationship 
with,  and  possibly  of  older  standing  than,  the  renal 
lesion  which  is  coexistent  with  it.  One  case  in  Perry 
and  Shaw's  series  (No.    151)  is,  as  they  point  out,  dis- 


Fig.  11. — UiLEMic  Ulceration  of  Duodenum. 

R.  B.,  male,  aged  forty-eight,  admitted  November  7,  1904,  under  Dr. 
Penrose.  A  very  muscular,  tall  man,  admitted  with  marked  oedema  of 
both  lower  extremities.  For  sixteen  years  has  passed  small  calculi  in  the 
urine.  Died  from  failure  of  the  right  heart  twelve  days  after  admission. 
At  the  post-mortem  the  following  conditions  were  found: 

Kidneys:  Right,  9  ounces;  left,  3  ounces.  The  right  is  large.  The 
left  is  small  with  adherent  capsules,  and  the  fat  around  is  firmly  adherent 
to  both.  On  section,  in  the  lower  lobe  of  the  right  is  a  fairly  large  renal 
calculus  in  three  pieces.  The  calculus  is  black  in  colour  and  surrounded 
by  phosphates.  In  the  left  there  are  two  minute  similar  calculi.  The 
pelves  of  both  kidneys  are  inflamed,  but  not  particularly  dilated.  Both 
ureters  are  dilated  from  end  to  end  and  firmly  adherent  to  the  surrounding 
fat.     Their  walls  are  thickened  and  their  lining  membranes  are  infected 


Uraemic  Ulcer  of  the  Duodenum  47 

tinguished  at  once  from  the  rest  inasmuch  as  the  causal 
relation  of  the  nephritis  to  the  duodenal  ulceration 
appears  to  be  indisputable.  "It  is  that  of  a  man,  aged 
thirty-six,  who  was  admitted  for  albuminuria  and 
diarrhoea,  his  illness  dating  from  two  months  before  his 
admission.  He  had  passed  blood  in  his  motions.  He 
died  after  he  had  been  in  hospital  three  days,  and  on 
post-mortem  examination  his  kidneys  were  found  to  be 
extremely  cirrhotic,  and  the  left  ventricle  of  the  heart 
was  hypertrophied.  Ulcerated  areas,  such  as  are  com- 
mon in  Bright's  disease,  were  found  scattered  through 
the  large  and  small  intestines,  and  the  lower  half  of  the 
duodenum  was  similarly  affected.  This  case  seems  to 
prove  that  the  ulcerative  enterocolitis  of  Bright's  dis- 
ease may,  though  rarely,  extend  as  high  as  the  duode- 
num. In  all  the  other  cases  there  is  an  absence  of 
marked  enteritis  in  the  lower  part  of  the  intestine,  and 
ilie  conditions  observed  in  the  duodenum  do  not  mate- 


ami   inflamed.     Half-way  down   the  right   two   portions  of  calculus  are 
impai  I 

Ureters:   The  orifices  of  the  ureters  into  the  bladder  are  not  noticeably 
dilated.     The  left  opening  is,  however,  larger  than  the  right. 

Bladder:    The  vesical  lining  membrane  is  generally  infected  and  swollen 
from  inflammation.     This  lesion,  however,  is  not  advan 

Prostate:   Normal. 

Alimentary  Canal:    The  stomach   and  intestines  are  much  congestedi 
the  former  shewing  chronic  gas(  rit  is  as  well. 

In  the  duodenum,  from  the  pylorus  to  jusl  above  the  bile  papilla,  are  nine 
ulcerated  patches.  These  patches  are  scattered  about,  the  largest  being 
o\  er  one  inch  long;  all  are  irregular  in  outline,  with  swollen,  not  undermined 
edges,  and  smooth  floors;  the  floor  in  everj  case  is  a  deep  greyish-black 
in  colour.  No  other  ulcers  are  seen  in  the  intestinal  tract,  the  colon,  in 
particular,  being  normal.  The  small  gul  as  a  whole,  in  addition  to  being 
congested,  is  oedematous  and  contains  altered  blood  (St.  <  ieorge's  Hos 
pita!  Museum,  Specimen  90  I 


48  Duodenal  Ulcer 

rially  differ  from  those  in  cast's  where  Bright' s  disease  is 
not  present." 

In  the  case  reported  by  Barie  and  Delaunay  the  upper 
part  of  the  small  intestine  was  deeply  congested,  and  the 
duodenum  contained  four  recent  ulcerations,  from  one 
of  which  a  haemorrhage  had  occurred  so  copious  as  to 
till  the  large  intestine  and  a  part  of  the  small  intestine 


•v 


Fig.  12. — Perforating  Ulcer  of  the  Duodenum  (Possibly  Ur/emic). 

In  the  anterior  wall  of  the  duodenum,  just  beyond  the  pylorus,  is  a  round, 
clean-cut  perforation,  of  the  calibre  of  a  quill.  The  mucous  and  muscular 
coats  of  the  gut  are  destroyed  to  a  slightly  greater  extent  than  the  peritoneal 
layer.  The  wall  of  the  bowel  is  thickened,  but  not  to  a  great  extent,  around 
the  perforation. 

From  the  body  of  a  painter,  aged  fifty-six,  the  subject  of  granular 
disease  of  the  kidneys,  who  died  in  the  hospital  of  peritonitis  resulting  from 
the  perforation  for  which  he  was  admitted.  The  origin  is  not  apparent. 
(St.  George's  Hosp.  Museum,  No.  89  A.) 


with  blood.  There  were  no  ulcerations  or  erosions  in 
the  colon.  In  two  cases  in  Perry  and  Shaw's  list  (Nos. 
58  and  59)  haemorrhagic  erosions  of  the  duodenum  were 


-     Uraemic  Ulcer  of  the  Duodenum  49 

found  in  association  with  morbid  changes  in  the  kidney. 
In  one  case — the  only  one  observed  in  my  series  of 
cases — an  extensive  ulcer  of  the  duodenum  seemed  to  be 
dependent  upon  an  advanced  pathological  condition  of 
the    kidneys.     In    all    these    examples    the    ulceration 


Fig.  13. — I'r.e.mic  Ulceration  of  the  Duodenum. 
F.  B.,  female,  aged  seventy-four.  Admitted  October  26,  1904,  under  the 
care  of  Dr.  Ewart,  for  a  failing  heart.  There  was  much  oedema  of  the  lower 
extremities  and  the  abdomen  contained  a  large  quantity  of  fluid.  Both 
kidneys  were  granular,  and  the  duodenum  contained  in  its  first  part  nine 
irregularly  shaped  ulcers,  with  deep  black  bases.  No  other  ulcers  were 
present  in  the  intestinal  tract.      (St.  George's  rlosp.  Museum,  No.  90  F.) 

involved  chiefly  the  mucosa,  it  was  extensive  or  seen 
in  multiple  point-,  associated  with  congestion  or  haemor- 
rhagie  erosion  in  other  parts  of  the  inner  surface  of  the 
bowel,  and  no  evidence  of  attempted  repair  was  any- 
where displayed.  The  process  was  chiefly,  if  not  wholly, 
4 


5o 


Duodenal  Ulcer 


one  of  destruction.     In  circumstances  such  as  these  the 
evidence    would,    I    think,    support    the   view    that    the 


Fig.  14. — Duodenal  I'lcer. 

The  first  portion  of  a  duodenum  with  the  adjacent  end  of  the  stomach 
laid  open  to  display  an  oblong  ulcer  in  the  former.  It  is  situated  an  inch 
beyond  the  pylorus,  and  measures  nearly  an  inch  in  its  chief  diameter, 
which  is  transverse.  The  margin  of  the  ulcer  is  thickened  and  undermined, 
while  its  base  is  loosely  attached  to  the  subjacent  head  of  the  pancreas. 
A  vertical  section  shews  that  the  common  bile-duct  is  in  close  relation  with 
the  floor  of  the  ulcer.  A  blue  rod  marks  the  course  of  the  duct.  Close 
to  the  pyloric  ring  the  depressed  scars  of  two  healed  duodenal  ulcers  may 
be  seen. 

From  a  boy,  aged  seventeen,  who  was  admitted  for  nephritis  and 
anasarca.  He  died  of  uraemia,  five  months  after  the  onset  of  his  illness, 
having  previously  enjoyed  very  good  health.  (Royal  College  of  Surgeons 
Museum,  No.  2430  A.     Presented  by  Guy's  Hospital,  1893.) 

lesion  in  the  bowel  is  secondary  to  the  disease  of  the 
kidneys.  The  ulcer  is  almost  always  confined  to  the 
first    portion    of    the    duodenum,    and    (with    only    one 


Uraemic  Ulcer  of  the  Duodenum  ;i 


3 


exception)  lies  above  the  ampulla  of  Yater.  The  ulcer 
is,  as  a  rule,  solitary,  but  two,  three,  four,  and  five 
separate  ulcers  have  been  noticed.  The  ulcers  may  be 
at  the  summit  of  the  valvulse  conniventes,  but  more 
often  are  found  as  furrows  or  chaps  on  the  under  sur- 
face of  these  folds,  at  their  points  of  attachment  to  the 
intestinal  wall.  The  depth  of  the  ulcer  varies  consider- 
ably: there  may  be  only  the  slightest  surface  erosion, 
or  the  whole  thickness  of  the  intestinal  wall  may  be 
destroyed,  so  that  the  pancreas  is  eaten  into,  an  artery 
of  large  size  eroded,  the  common  bile-duct  or  the  gall- 
bladder laid  open,  or  the  general  cavity  of  the  peritoneum 
invaded.  Death  may  occur  from  haemorrhage  or  from 
perforation.  In  order  to  ascertain  if  there  is  any  causal 
relation  between  the  condition  of  the  kidneys  and  the 
ulceration  of  the  duodenum  Perry  and  Shaw  estimated 
from  the  post-mortem  records  of  Guy's  Hospital  the 
percentage  of  persons  dying  from  nephritis;  they  found 
that  some  form  of  kidney  disease  was  present  in  7  per 
cent,  of  deaths.  Their  cases  of  duodenal  ulcer  numbered 
70,  and  of  these,  7  per  cent.,  or  5  cases,  might  have  been 
expected  to  have  coincident  Bright's  disease.  As  a 
matter  of  fact,  12  cases  shewed  this  association,  and 
"there  appears  therefore  to  be  some  reason  for  including 
Bright's  disease  as  one  of  the  predisposing  causes  of 
duodenal  ulcer."  The  form  of  the  kidney  disease 
varies:  there  may  be  interstitial  nephritis,  tubal  neph- 
ritis, or  a  combination  of  the  two. 

The  direct  causation  of  the  ulcers  has  not  been  satis- 
factorily explained.  Treitz,  in  his  original  description 
of  the  condition,  ascribed  the  origin  of  the  ulcers  to  the 


5^ 


Duodenal   Ulcer 


irritation  of  the  mucosa  set  up  by  the  excretion  of  am- 
monium carbonate.  W.  H.  Dickinson  ("Med.  Chir. 
Trans.."  1S94,  lxxvii,  111)  suggested  that  the  ulceration 


Fig.  15. — Typhoid  Ulceb  of  Duodenum. 

A  small,  somewhat  triangular,  typhoid  ulcer  (marked  by  a  piece  of 
blue  glass  rod)  is  situated  almost  immediately  beyond  the  pyloric  rings. 
The  ulcer  had  perforated,  causing  general  septic  peritonitis.  (Great 
Northern  Central  Hospital,  Xo.  121.) 


might  be  secondary  to  submucous  hemorrhages,  the 
evidences  of  which  are  not  seldom  seen  side  by  side  with 
the  ulcerated  patches.     Baric  ("Arch.  Gen.  de  Med.," 


Uraemic  Ulcer  of  the  Duodenum 


53 


1899,  ii,  415)   considers  that  "as  a  result  of  the  renal 
insufficiency,  there    are    soon    developed    other,    supple- 


Fig.  16. — Anthrax  of  the  Duodenum. 
Three  pieces  of  a  duodenum  mounted  to  illustrate  the  effects  of  anthrax. 
The  topmost  piece  shews  beneath  the  mucous  membrane  a  flattened  nodule 
measuring  about  half  an  inch  in  diameter  and  a  sixteenth  of  an  inch  in 
thickness.  It  was  situated  at  the  lower  end  of  the  duodenum,  and  in  the 
recenl  state  the  mucous  membrane  covering  it  presented  a  small  central 
slough.  The  two  lower  pieces  -hew  brown  dots  and  patches  resulting  from 
submucous  haemorrh a 

Walter  Ii..  set.  thirty-nine,  was  admitted  under  Mr.  Durham  tor  a  "malig- 
nant pustule"  upon  the  neck,  which  had  been  first  noticed  as  a  little  pimple 
four  days  before  admission.     The  i>u>tule  was  immediately  excised.     Two 
-  later  the  patient  died.     At  the  autopsy  the  cellular  tissue  of  the  neck 
found  to  be  oedematous,  .md  then-  was  considerable  haemorrhage  be- 
neath the  arachnoid.     NO  part  of  the  alimentary  canal  appeared  to  be 
ted  with  anthrax  except  the  duodenum.     The  peritoneal  cavitj  con- 
tained about  thin\  ounces  of  yellowish  fluid.     (See  Insp.  1884,  No.  113.) 


^4  Duodenal  Ulcer 

mentary  paths  for  the  elimination  of  the  urinary  poisons. 
These  are  established  chiefly  through  the  respiratory 
passages,  by  the  skin,  and  perhaps  by  some  of  the  serous 
membranes.  But  it  is  chiefly  the  alimentary  canal 
which  becomes  the  principal  medium  of  excretion,  and 
it  is  therein  that  the  signs  of  irritation,  stomatitis, 
d\>pepsia,  gastralgia,  vomiting,  and  diarrhoea  may 
arise."  This  hypothesis  of  the  excretory  activity  of  the 
intestinal  tract  in  cases  of  uraemia  is  fully  supported  by 
the  experimental  work  of  Stassano  ("Soc.  de  Biologie," 
1902,  ii,  24),  which  seems  to  shew  the  particular  and 
special  efficiency  of  the  duodenum  in  the  excretion  of 
urinary  toxines.  Acute  ulceration  of  the  duodenum 
occurring  in  cases  of  anthrax,  typhoid  fever,  and  pem- 
phigus, etc.,  may  perhaps  be  thus  in  part  explained. 

The  following  is  a  complete  list  of  all  recorded  cases  of 
unemic  duodenal  ulcer: 


Case  I. — Haemorrhagic  erosions  of  the  duodenum:  Sarah 
\\  — ,  aet.  twenty-nine,  was  admitted  under  Dr.  Rees  for 
gout  and  dropsy.  Some  months  later  she  died,  and  at  the 
autopsy  there  was  oedema  of  the  lower  extremities,  with  tubal 
and  interstitial  nephritis,  chronic  peritonitis,  and  perihepatitis. 
There  was  also  acute  recent  pericarditis,  and  much  fluid  in  the 
right  chest.  In  the  duodenum  were  several  eroded  ulcers 
with  edges  sharply  defined  and  bases  occupied  by  adherent 
blood-clot.  The  ulceration  was  superficial,  involving  only 
the  mucous  membrane.      (Perry  and  Shaw,  Case  58,  p.  230.) 

Case  2. — Haemorrhagic  erosions  of  the  duodenum:  Eliza- 
beth I  !  — ,  aet.  thirty-six,  was  admitted  under  Dr.  Pitt  three 
days  after  the  onset  of  a  right  hemiplegia.  Albumen  and  casts 
were  found  in  the  urine.  Four  days  after  her  admission  she 
became  comatose  and  died.  At  the  autopsy  there  was  chronic 
interstitial  nephritis  with  some  distension  of  the  pelves  of  the 


Uraemic  Ulcer  of  the  Duodenum  55 

kidneys.  There  were  a  few  small  hemorrhagic  erosions  in  the 
duodenum.  The  lungs  were  congested  and  cedematous;  the 
heart  was  normal.     (Perry  and  Shaw,  Case  59,  p.  230.) 

Case  3. — Ulcer  of  the  duodenum  and  stomach;    cellulitis; 

nephritis:    John  B ,  aet.  fifty-six,  was  admitted  under  Mr. 

Cock  for  cellulitis  of  the  leg.  He  lingered  for  many  weeks, 
and  at  the  autopsy  the  right  leg  was  found  to  be  in  a  slough- 
ing state  from  the  hip  downwards.  There  was  a  chronic 
ulcer  on  the  lesser  curvature  of  the  stomach.  It  was  rather 
larger  than  a  shilling,  perfectly  round,  and  with  raised,  smooth 
edges.  The  floor  was  composed  solely  of  the  peritoneal  mem- 
brane, and  this  was  so  thin  as  to  be  quite  diaphanous.  There 
was  a  small,  round,  superficial  ulcer  at  the  commencement  of 
the  duodenum,  and  another  in  the  ascending  colon.  The 
kidneys  shewed  tubal  and  interstitial  nephritis.  (Perry  and 
Shaw,  Case  92,  p.  237.) 

Case  4. — Suppurating  knee-joint;  tubal  nephritis;  ulcer 
of  duodenum;  haemorrhage:  A  male  with  grey  hair  was  ad- 
mitted under  Mr.  Cooper  Foster  with  a  suppurating  knee- 
joint.  Amputation  was  performed.  He  rallied  imperfectly, 
had  signs  of  fever,  and  sank.  He  did  not  vomit  until  the  day 
of  his  death  and  no  blood  was  ever  noticed  in  his  motions. 
At  the  autopsy  the  stump  presented  a  healthy  granulating 
surface.  There  was  recent  pleurisy  and  pericarditis  and  a 
moderate  degree  of  mitral  stenosis.  The  kidneys  weighed 
13  ounces  and  were  rather  granular  on  the  surface,  but  other- 
wise in  the  state  of  large  white  change  with  prominent  stellate 
veins.  On  the  hinder  surface  of  the  duodenum,  half  an  inch 
beyond  the  pylorus,  was  a  deep  excavation  of  the  size  and  form 
of  half  a  chestnut;  this  exposed  the  pancreas,  the  duodenum 
being  fastened  at  this  point  very  firmly  to  the  gland  by  a  dense 
tissue.  There  was  a  small  elevation  in  the  ulcer,  and  a  little 
artery  here  projected  from  the  panereat  ieo-duodenal.  On 
opening  up  the  artery  a  weak  thin  patch  was  found  in  it.  at 
which  the  rupture  had  taken  place.  The  intestines  were  full 
of  blood,  little  altered  in  character,  and  the  Stomach  contained 

much  half-digested  blood.     I  Perry  and  Shaw,  Case  94,  p.  238.) 

CASE  5. — Burn;     ulcer  of  the  duodenum:     A   girl,   aet.   six, 

was  admitted  into   St.  George's  Hospital   under  Mr.   Keate 


56  Duodenal  Ulcer 

for  severe  burns,  which  two  months  later  were  sloughing. 
She  died  seventy-five  days  after  the  accident;  and  at  the 
autopsy  three  ulcers  were  found  in  the  first  part  of  the  duo- 
denum; the  largest,  which  was  about  the  size  of  a  four- 
penny  piece,  being  within  half  an  inch  of  the  pylorus,  the 
other  two  being  close  to  the  first.  In  the  largest  pair  the 
base  was  formed  by  the  muscular  tissue;  the  smallest  one 
was  quite  superficial.  Both  kidneys  "presented  well-marked 
specimens  of  the  mottling  degeneration."  The  duodenal 
glands  were  somewhat  increased  in  size.  (Perry  and  Shaw, 
Case  133,  p.  247.) 

Case  6. — Granular  kidneys;    cirrhotic  liver;    ulcer  of  the 

duodenum;     haemorrhage:     Harriet    H ,    set.    thirty-five, 

was  admitted  under  Dr.  Bright  in  1834  f°r  vomiting  and 
albuminous  urine.  The  vomit  sometimes  contained  blood. 
She  died  twelve  days  after  admission,  and  at  the  autopsy  the 
mucous  membrane  of  the  stomach  was  much  injected,  and 
at  several  minute  points  apparently  ulcerated.  A  simple 
ulcer  of  irregular  figure,  about  the  size  of  a  sixpence,  and 
resembling  the  complete  and  abrupt  removal  of  so  much 
mucous  membrane,  was  found  in  the  duodenum.  The  ulcer 
had  slightly  injected  edges,  and  there  were  patches  of  con- 
gestion in  the  rest  of  the  small  intestine.  The  liver  was 
cirrhotic  and  the  kidneys  were  small  and  granular.  (Perry 
and  Shaw,  Case  145,  p.  250.) 

Case  7. — Contracted  granular  kidneys;  ulcer  of  the  duo- 
denum and  stomach:    Elizabeth  M ,  set.  forty-one,  was 

admitted  under  Dr.  Babington  in  1841  for  Bright's  disease. 
Symptoms  of  peritonitis  supervened,  and  she  died  one  month 
after  her  admission.  At  the  autopsy  the  kidneys  were  found 
to  be  small  and  granular,  and  there  was  a  contracted  ulcer 
in  the  beginning  of  the  duodenum,  and  a  smaller  and  more 
recent  one  upon  the  pyloric  ring.  (Perry  and  Shaw,  Case 
146.) 

Case   8. — Granular   kidneys;     follicular   ulceration   of   the 

duodenum:    John  P ,  act.  fifty-seven,  was  admitted  under 

Dr.  Babington  with  malignant  disease  of  the  oesophagus, 
from  which  five  weeks  later  he  died.  At  the  autopsy  a  stric- 
ture was  found  an  inch  and  a  half  from  its  cardiac  end.     The 


Uraemic  Ulcer  of  the  Duodenum  57 

stomach  was  contracted  and  its  mucous  membrane  con- 
gested. It  contained  an  abundance  of  stringy  mucus.  The 
duodenum  was  intensely  injected  and  presented  numerous 
enlarged  glands,  many  of  which  were  ulcerated,  the  larger 
ulcers  being  close  to  the  pylorus.  The  rest  of  the  alimentary 
canal  was  normal,  but  exceedingly  contracted  and  quite  empty. 
The  kidneys  were  small  and  the  cortex  was  diminished  in 
thickness.     (Perry  and  Shaw,  Case  147.) 

Case    9. — Interstitial    nephritis;*   atheroma;      perforating 

ulcer  of  the  duodenum:    Charles  W ,  aet.  sixty-six,  was 

admitted  under  Dr.  Rees  for  oedema  of  the  lower  extremities 
and  weakness.  He  had  always  been  healthy  till  within  a 
few  weeks  of  -his  admission.  His  urine  was  found  to  be 
highly  albuminous.  He  died  a  fortnight  after  his  admission, 
but  there  is  no  clinical  account  of  the  symptoms  immediately 
preceding  his  death.  At  the  autopsy  the  kidneys  were  found 
to  be  granular  and  there  was  an  old  apoplectic  cyst  in  the 
pons.  The  vessels  were  atheromatous  'and  the  heart  hyper- 
trophied.  The  abdominal  cavity  contained  about  three  pints 
of  turbid  offensive  fluid.  The  surface  of  the  peritoneum  was 
coated  with  lymph  in  some  quantity,  and  reddened  also  by 
fine  capillary  injection.  The  cause  of  this  peritoniti>  was 
perforation  of  the  duodenum  by  an  ulcer  close  to  the  pylorus 
on  the  upper  aspect.  The  ulcer  was  of  the  size  of  a  horse 
bean,  and  very  clean-cut,  having  quite  the  "punched"  ap- 
pearance. The  whole  circumference  of  the  proximal  portion 
of  the  duodenum  for  a  width  of  one  and  a  half  inches  from  the 
pyloric  ring  was  curiously  diseased,  so  that  there  appeared  to 
be  gland  tissue  in  the  submucous  substance,  and  this  formed  .1 
layer  movable  on  the  coats  beneath,  and  of  the  thickness  ol  a 
penny  piece.  At  one  spot  this  had  yielded  like  an  aneurysmal 
bulging,  and  at  another  spot,  opposite  to  the  hole  above  de- 
scribed, thai  i>,  on  the  lower  bonier  of  the  gut,  there  was  .1 
second  small  ulcer  with  abrupt  margin  and  some  ^>lt  blood- 
clot  on  its  base,  which  was  formed  by  the  submucous  tissue. 
I  Terr)'  and  Shaw,  (  !ase  14H.) 

Case  10.  Tubal  nephritis;  ulcers  ol  the  duodenum,  one 
partly  cicatrised:  Eliz.  W  .  set.  fifty-five,  was  admitted 
under  Dr.   Moxon  with  vomiting,  dropsy,  and  albuminuria, 


58  Duodenal  Ulcer 

of  which  she  died.  At  the  autopsy  the  pleural  cavities  con- 
tained a  large  quantity  of  serous  fluid  and  the  kidneys  were 
affected  by  tubal  nephritis.  Just  beyond  the  pyloric  ring 
the  duodenum  contained  two  ulcers,  one  two  inches  in  length, 
beginning  just  on  the  distal  side  of  the  pyloric  ring,  and  the 
other,  which  was  partly  cicatrised,  three-quarters  of  an  inch 
from  the  valve.     (Perry  and  Shaw,  Case  149.) 

Case    11. — Granular    kidneys;     ulcer    of    the    duodenum 
opening  the  gastro-duodenal  artery  and  common  bile-duct: 

Thomas    M ,    aet.    forty-eight,    was   admitted    under    Dr. 

Wilks  for  persistent  abdominal  pain  of  five  months'  dura- 
tion. Eleven  years  previously  he  had  had  pain  in  the  abdo- 
men, which  was  severe  and  lasted  several  weeks,  and  he 
had  had  two  or  three  attacks  since  that  time.  He  was  a 
plumber  and  painter,  and  there  was  a  lead  ring  on  his  gums. 
There  was  slight  jaundice.  Twenty-eight  days  after  his 
admission  he  was  suddenly  seized  with  great  pain  in  the 
right  hypochondrium.  He  became  pale  and  collapsed,  and 
subsequently  passed  black  stools.  He  then  sank  into  a 
drowsy  condition,  and  died  four  days  later.  At  the  autopsy 
urate  of  soda  was  found  in  the  joints,  the  kidneys  were  granular, 
and  the  left  ventricle  of  the  heart  was  hypertrophied.  The 
cardiac  muscle  shewed  extensive  fatty  (tabby)  degeneration. 
Immediately  below  the  pyloric  ring  the  duodenum  presented 
a  somewhat  quadrilateral  shaped  ulcer  with  thick,  indurated 
edges  and  a  considerably  depressed  base.  The  floor  of  the 
ulcer  was  formed  by  the  upper  edge  of  the  pancreas  and  the 
portal  fissure,  which  contained  a  considerable  excess  of  fibrous 
tissue.  Close  to  the  pyloric  ring  was  an  aperture  which  opened 
into  the  gastro-duodenal  artery,  and  to  the  right  of  this  was  a 
very  similar  elongated  aperture,  from  which  bile  flowed  freely 
on  squeezing  the  gall-bladder.  It  led  into  the  common  duct 
about  one  inch  from  its  termination.  The  hepatic  duct  in  the 
portal  fissure  was  considerably  dilated  and  its  walls  were  thick, 
but  there  was  no  obstruction  to  the  exit  of  the  bile  then  present. 
The  duodenum  contained  bilious  contents.  Throughout  the 
intestine  was  some  jelly-like  mucus,  but  only  in  the  splenic 
flexure  of  the  colon  was  there  any  blood.  (Perry  and  Shaw, 
Case  150.) 


Uraemic  Ulcer  of  the  Duodenum  59 

Case  12. — Ulceration  of  the  duodenum;  interstitial  neph- 
ritis:   George  B ,  set.  thirty-six,  was  admitted  under  Dr. 

Wilks  with  albuminuria  and  excessive  diarrhoea.  His  illness 
was  stated  to  have  commenced  two  months  before  his  admis- 
sion. On  the  day  after  his  admission  he  passed  some  blood 
and  became  delirious,  with  a  subnormal  temperature.  He 
died  three  days  after  admission,  and  at  the  autopsy  his  kidneys 
were  found  to  shew  an  extreme  degree  of  interstitial  nephritis 
and  the  left  ventricle  of  the  heart  was  hypertrophied.  The 
stomach  was  practically  healthy,  as  was  also  the  upper  half 
of  the  duodenum;  below  this  there  was  extensive  ragged 
ulceration  all  around  the  bowel,  the  mucous  surface  having 
entirely  disappeared  in  parts,  leaving  a  finely  flocculated  sur- 
face behind.  The  ulcers  appeared  to  commence  at  the  angle 
of  reflection  of  the  valvulae  conniventes,  and  in  many  places 
the  larger  valvulae  overlapped  and  hid  them.  There  was  a 
notable  absence  of  any  thickening  of  the  edge  of  the  ulcers, 
but  much  dark,  slaty  pigment  in  the  submucous  tissue,  and 
also  in  the  mucous  membrane  itself,  where  it  remained.  The 
ulcerated  state  extended  a  short  way  into  the  jejunum. 
Similar  ulcerated  areas  were  found  in  other  parts  of  the  small 
and  large  intestines,  the  affection  of  the  latter  being  less 
severe  than  of  the  former.     (Perry  and  Shaw,  Case  151.) 

Case    13. — Acute   upon   chronic   nephritis;     ulcers   of   the 

duodenum:     Arthur    M ,    set.    forty-two,    was    admitted 

under  Dr.  Moxon  with  vomiting,  abdominal  pain,  and  albu- 
minuria. Fourteen  days  after  admission  he  suffered  from 
diarrhoea,  and  passed  half  a  pint  of  blood  by  the  rectum. 
He  was  found  to  have  a  fistula  and  a  few  haemorrhoids;  the 
former  was  operated  upon,  and  no  blood  was  passed  in  the 
motions  afterwards.  Anasarca  supervened,  the  vomiting 
persisted,  the  urine  contained  blood-corpuscles  and  epithelial 
casts,  he  became  delirious,  and  died  comatose  about  two 
months  after  his  admission.  At  the  autopsy  the  lungs  were 
oedematous,  the  left  ventricle  hypertrophied,  and  the  kidneys 
were  found  in  a  condition  of  acute  nephritis,  weighing  1  7  \  ■_■ 
ounces.  In  the  abdomen,  about  an  inch  beyond  the  pylorus, 
was  situated  an  ulcer  of  about  a  square  inch  in  area,  with  an 
irregular,  slightly  raised  edge  and  .1  base  formed  b)   the  pan- 


6o  Duodenal  Ulcer 

crcas.  Towards  the  stomach  the  edge  was  much  under- 
mined, but  there  was  no  perforation  into  the  peritoneal 
cavity.  Opposite  this  ulcer  was  another  round,  punched- 
out  ulcer,  the  size  of  a  sixpenny-piece,  which  had  perforated 
and  reached  the  under  surface  of  the  gall-bladder,  which 
formed  the  floor  of  the  ulcer.  The  solitary  follicles  of  the 
small  intestine  were  enlarged.  There  was  a  small  peduncu- 
lated polypus  in  the  sigmoid  flexure  of  the  colon.  (Perry 
and  Shaw,  Case  152.) 

Case  14. — Calculus  vesicae;    tubal  nephritis;    chronic  ulcer 

of    the   duodenum,    practically    healed:     George   K ,    set. 

sixty-two,  was  admitted  under  Mr.  Bryant  with  symptoms  of 
stone,  from  which  he  had  suffered  for  eight  years.  Lithot- 
omy was  performed,-  and  two  large  stones  were  removed 
from  the  bladder.  He  became  delirious  and  died  two  days 
later.  At  the  autopsy  the  kidneys  shewed  tubal  nephritis, 
and  in  the  duodenum  was  a  chronic  ulcer  just  beyond  the 
pylorus,  with  a  linear  cicatrix  running  from  it.  (Perry  and 
Shaw,  Case  153.) 

Case   15. — Tubal  nephritis;    recent  and  healed  ulcers  of 

the  duodenum:    John   L ,   get.   seventeen,   was  admitted 

under  Dr.  Pye-Smith  for  dropsy,  from  which  he  had  suffered 
for  nine  weeks.  On  admission  the  urine  was  found  to  con- 
tain blood,  albumen,  and  casts.  The  patient  died  three 
months  after  admission,  and  at  the  autopsy  the  kidneys 
were  seen  to  be  in  a  condition  of  chronic  tubal  nephritis. 
"One  and  a  half  inches  beyond  the  pylorus,  in  the  first  part 
of  the  duodenum,  there  was  an  oval  ulcer  measuring  one  and 
a  half  inches  by  three-quarters  of  an  inch,  the  longer  diameter 
of  which  was  directed  across  the  bowel.  The  edges  of  the 
ulcer  were  irregular  and  undermined,  and  its  base  was  ragged 
and  sloughing.  The  duodenum  was  not  unduly  adherent 
to  the  neighbouring  tissues.  Close  to  the  recent  ulcer  there 
were  two  healed  ulcers."      (Perry  and  Shaw,  Case  154.) 

Case  16. — Granular  kidneys;  perforating  ulcers  of  the 
duodenum:  A  male,  whose  age  is  not  given,  but  who  appears 
to  have  been  about  forty,  entered  a  public-house  at  twelve 
o'clock,  and  was  supplied  with  a  glass  of  beer  and  porter 
mixed.     He  sat   down  and  took  up  the  newspaper,  but   soon 


Uraemic  Ulcer  of  the  Duodenum  61 

complained  of  feeling  unwell,  and  placed  his  hand  over  the 
epigastric  region,  where  he  said  he  had  pain.  He  sat  there 
for  some  time,  and  at  half  past  one  was  noticed  asleep,  as 
some  thought;  but  as  he  continued  so,  and  looked  pale,  an 
attempt  was  made  to  waken  him,  when  he  was  found  to  be 
dead.  It  appeared  that  he  had  had  slight  abdominal  pain 
the  previous  night,  and  severe  pain  at  eight  o'clock  in  the 
morning,  for  which  he  took  a  little  brandy.  At  the  autopsy 
the  abdominal  cavity  was  found  to  contain  a  quantity  of 
darkish  brown  liquid  devoid  of  any  particular  odour,  but 
having  a  greasy  appearance  on  its  surface  and  an  acid  re- 
action. Half  an  inch  from  the  pylorus,  on  the  upper  and  outer 
side  of  the  first- portion  of  the  duodenum,  there  was  found  a 
large,  oval-shaped  opening,  half  an  inch  long  and  of  nearly 
the  same  width.  There  was  reddening  and  injection  of  the 
peritoneum,  but  no  lymph  was  effused.  Seen  from  the  in- 
side of  the  duodenum,  the  ulcer  was  slightly  funnel-shaped, 
and  the  edges  were  thickened  and  hard'.  The  upper  border 
of  the  ulcer  was  not  more  than  a  quarter  of  an  inch  from  the 
pylorus,  which  was  quite  healthy.  The  mucous  membrane 
lining  the  lower  portion  of  the  duodenum  was  of  a  deepish 
red  colour.  All  the  other  intestines  were  healthy.  The 
mucous  membrane  of  the  stomach  was  reddened,  but  free 
from  ulceration.  The  liver  was  fatty  and  the  kidneys  were 
slightly  granular.  The  heart  appears  to  have  been  normal, 
except  for  slight  atheroma  of  the  mitral  valve.  The  brain 
was  healthy.  The  case  is  recorded  by  Mr.  J.  S.  Fletcher 
in  the  "Association  Medical  Journal,"  1854,  p.  735.  (Perry 
and  Shaw,  Case  155.) 

Case    17. — -Granular    kidneys;     perforating    ulcer    of    the 

duodenum:     ().  S ,   a  large   robusl    man,   set.   sixty,   was 

admitted  into  the  Cholera  Wards  of  the  London  Hospital  in 
1867  suffering  with  severe  pain  in  the  right  side  of  the  abdo- 
men, vomiting,  feeble  pulse,  and  cold  extremities,  lie  had 
been  at  work  as  a  carman  till  within  an  hour  of  his  admis- 
sion, and  it  was  whilst  at  work  that  he  was  seized  with  the 
severe  abdominal  pain  mentioned  above.  For  t  lie  firsl 
twenty-four  hours  he  was  supposed  to  be  suffering  from  colic, 

,iik1  he  died  with  evident    signs  of  peritonitis  about    thirty-six 


62  Duodenal  Ulcer 

hours  after  his  admission.  His  wife- was  certain  that  he  had 
made  no  complaint  of  ill  health,  except  that  for  a  few  weeks  he 
had  experienced  a  sense  of  weight  after  taking  food.  At  the 
autopsy  the  peritoneal  cavity  contained  lymph  and  a  large 
quantity  of  thick  yellow  fluid,  on  the  surface  of  which  was  a 
fatty-looking  matter.  (The  patient  had  taken  castor  oil  in 
the  hospital.)  In  the  duodenum,  about  three  lines  from  the 
pylorus,  was  an  opening  about  the  size  of  a  fourpenny-piece, 
having  a  thin,  well-defined  margin  and  surrounded  by  a  circle 
of  thickened  tissue.  The  gastrointestinal  mucous  membrane 
was  otherwise  healthy.  Extensive  granular  degeneration  of 
both  kidneys  was  present,  and  the  heart  weighed  18  ounces. 
(Perry  and  Shaw,  Case  156.) 

Case  18. — Granular  kidneys;  perforating  ulcer  of  the 
duodenum:  Henry  H ,  set.  fifty-six,  a  painter,  was  ad- 
mitted into  St.  George's  Hospital  under  Dr.  Wadham  suffering 
from  severe  abdominal  pain.  He  had  a  hernia  which  had  come 
down,  and  which  he  was  unable  to  return.  Reduction  was 
easily  effected,  but  as  the  pain  continued  he  was  ordered  a  dose 
of  castor  oil  and  laudanum  and  sent  to  bed.  In  the  afternoon 
he  was  found  to  have  a  well-marked  blue  line  on  the  gums,  and 
as  there  was  a  history  of  three  previous  attacks  of  severe 
abdominal  pain,  lead  colic  was  diagnosed.  He  died  fourteen 
hours  after  his  admission,  and  at  the  autopsy  Dr.  Whipham 
found  evidence  of  recent  peritonitis,  the  small  intestines  being 
matted  together  by  soft  lymph.  On  the  anterior  surface  of 
the  first  portion  of  the  duodenum,  just  beyond  the  pylorus,  there 
was  a  small  perforation,  the  size  of  a  pea,  with  clearly  cut  edges. 
This  was  caused  by  a  small  ulcer,  the  edges  of  which  were  not 
thickened.  The  mucous  and  muscular  coats  were  only  slightly 
more  destroyed  than  the  serous.  No  other  ulcer  was  found. 
The  kidneys  were  granular,  the  cortex  diminished,  and  the 
capsules  adherent.     (Perry  and  Shaw,  Case  157.) 

Case  19. — Granular  kidneys;  contracting  ulcer  of  duode- 
num; haemorrhage:  John  H -,  aet.  sixty-three,  was  ad- 
mitted to  the  Westminster  Hospital  under  Dr.  Sturges  for 
collapse  and  severe  epigastric  pain.  He  slowly  recovered 
from  his  collapse,  but  presently  vomited  a  pint  of  blood, 
became  comatose,  and  died  about  an  hour  later.     Two  days 


Uraemic  Ulcer  of  the  Duodenum  63 

before  admission,  whilst  at  work,  he  was  seized  with  severe 
epigastric  pain  and  faintness.  He  recovered  so  far  as  to 
resume  his  occupation  as  a  blacksmith,  but  the  pains  and 
faintness  thereupon  recurring,  he  was  sent  into  the  hospital. 
At  the  autopsy  the  stomach  was  very  large  and  distended 
with  about  two  pints  of  black,  clotted  blood.  The  first 
part  of  the  duodenum  was  dilated,  resembling  a  small  second 
stomach,  and  in  it  was  a  punched-out  ulcer  about  the  size 
of  a  florin,  its  base  partly  formed  by  the  pancreas.  In  the 
floor  was  a  longitudinal  ulcerated  slit  about  a  quarter  of  an 
inch  long  which  opened  the  pancreatico-duodenal  artery. 
There  was  fluid  blood  in  the  oesophagus  and  intestines.  The 
kidneys  were  granular,  the  heart  hypertrophied,  and  there 
was  urate  of  soda  in  the  joints.  There  was  also  bronchiti- 
and  emphysema.  The  case  is  related  by  Dr.  Hebb. .  (Perry 
and  Shaw,  Case  158.) 

Case  20. — Ulcer  of  the  duodenum  associated  with  disease 
of  the  kidneys.  Man,  aged  fifty-six.  Suffered  for  some  time 
from  slight  haemorrhage  from  the  bowels,  and  vomited  black 
blood  on  several  occasions.  While  at  work  fainted,  and  was 
taken  to  hospital  in  a  state  of  collapse.  The  following  das- 
he  vomited  20  ounces  of  bright  blood  and  complained  of  pain 
in  the  epigastrium;  he  died  the  same  night.  At  the  post- 
mortem the  stomach  contained  a  considerable  quantity  of 
fluid  and  clotted  blood.  A  cicatrix  about  the  size  of  half  a 
crown  was  found  in  the  duodenum,  and  was  divided  into  two 
by  a  cut  extending  from  the  lesser  curvature  of  the  stomach. 
At  about  the  centre  was  a  clot  of  blood  blocking  the  opening 
into  a  larger  artery.  The  intestine  contained  blood.  The 
kidneys  were  large  and  cystic  and  contained  encapsulated 
masses  of  apparently  new  growth.     (Haldane,  "Edin.  Med. 

Jour.."    [86l    02,  Series  41.) 

There  are  two  specimens  ol  uraemic  ulceration  of  the 
duodenum  in  the  Museum  of  St.  George's  I  lospital.  The 
medical  registrar  has  kindly  allowed  me  to  take  the  fol- 
lowing notes  from   the  post-mortem   records: 


64  Duodenal  Ulcer 

Case  21. — F.  B.,  female,  aged  seventy-four.  Admitted 
October  26,  1904,  under  the  care  of  Dr.  Ewart,  for  a  failing 
heart.  There  was  much  oedema  of  the  lower  extremities  and 
the  abdomen  contained  a  large  quantity  of  fluid.  Both 
kidneys  were  granular,  and  the  duodenum  contained  in  its 
first  part  nine  irregular  shaped  ulcers,  with  deep  black  bases. 
No  other  ulcers  were  present  in  the  intestinal  tract.  (Spec- 
imen 90  F.)     (See  Fig.  13.) 

Case  22. — R.  B.,  male,  aet.  forty-eight,  admitted  Novem- 
ber 7,  1904,  under  Dr.  Penrose.  A  very  muscular,  tall  man, 
admitted  with  marked  oedema  of  both  lower  extremities. 
For  sixteen  years  has  passed  small  calculi  in  the  urine.  Died 
from  failure  of  the  right  heart  twelve  days  after  admission. 
At  the  post-mortem  the  following  conditions  were  found: 

Kidneys:  Right,  9  ounces;  left,  3  ounces.  The  right  is 
large.  The  left  is  small,  with  adherent  capsules,  and  the 
fat  around  is  firmly  adherent  to  both.  On  section,  in  the 
lower  pole  of  the  right  is  a  fairly  large  renal  calculus  in  three 
pieces.  The  calculus  is  black  in  colour  and  surrounded  by 
phosphates.  In  the  left  there  are  two  minute  similar  calculi. 
The  pelves  of  both  kidneys  are  inflamed,  but  not  particularly 
dilated.  Both  ureters  are  dilated  from  end  to  end  and  firmly 
adherent  to  the  surrounding  fat.  Their  walls  are  thickened 
and  their  lining  membranes  are  infected  and  inflamed.  Half- 
wax'  down  the  right  two  portions  of  calculus  are  impacted. 

Ureters:  The  orifices  of  the  ureters  into  the  bladder  are 
not  noticeably  dilated.  The  left  opening  is,  however,  larger 
than  the  right. 

Bladder:  The  vesical  lining  membrane  is  generally  infected 
and  swollen  from  inflammation.  This  lesion,  however,  is  not 
advanced. 

Prostate:    Normal. 

Alimentary  canal:  The  stomach  and  intestines  are  much 
congested,  the  former  shewing  chronic  gastritis  as  well. 
In  the  duodenum,  from  the  pylorus  to  just  above  the  bile 
papilla,  are  nine  ulcerated  patches.  These  patches  are 
scattered  about,  the  largest  being  over  one  inch  long;  all  are 
irregular  in  outline,  with  swollen,  not  undermined  edges,  and 
smooth  floors;    the  floor  in  every  case  is  a  deep  greyish-black 


Uraemic  Ulcer  of  the  Duodenum  65 

in  colour.  No  other  ulcers  are  seen  in  the  intestinal  tract, 
the  colon  in  particular  being  normal.  The  small  gut  as  a 
whole,  in  addition  to  being  congested,  is  cedematous  and  con- 
tains altered  blood.     (Specimen  90  E.)     (Fig.  11.) 

Case  23. — J.  H.,  aged  fifty-six,  labourer,  was  admitted 
under  Dr.  Saintsbury  on  November  19,  1891,  in  a  collapsed 
condition,  he  having  fainted  while  at  his  work.  He  had 
fainted  also  the  day  previously,  and  for  some  time  had  been 
subject  to  slight  attacks  of  haemorrhage  from  the  bowels  and 
vomiting.  There  was  some  alcoholic  history.  On  day  of 
admission  there  was  a  haematemesis  of  5  ounces,  and  recur- 
rence of  fainting  attack.  Two  days  after  admission  patient 
had  severe  epigastric  pain,  and  a  haematemesis  of  20  ounces, 
after  which  he  became  very  much  collapsed,  and  notwith- 
standing treatment  died  two  hours  later  (10.15  P.  M.,  Novem- 
ber 21,  1891).  Post-mortem  examination  found  a  duodenal 
ulcer  of  the  size  of  a  florin,  which  on  subsequent  microscopic 
examination  was  found  to  be  of  a  simple  nature.  And  there 
was  cystic  disease  of  both  kidneys.  (From  Royal  Free 
Hospital,  London.  Notes  kindly  supplied  by  Dr.  Adeline 
Roberts.  Specimen  xv,  6a,  581,  in  Royal  Free  Hospital 
Museum.) 

Case  24. — W.  Y.,  aged  seventy-four,  cab  driver,  admitted 
under  Mr.  Roughton  November  26,  1907,  with  history  of  six 
months'  alternating  constipation  and  diarrhoea.  Abdominal 
pain  two  days.  Vomited  once.  No  faeces  or  flatus  passed 
for  about  twenty-four  hours.  Pulse  120.  Abdomen  dis- 
tended, very  little  movement.  Signs  of  free  fluid.  Patient 
was  operated  on  at  once.  Turbid  fluid  and  gas  found.  Abdo- 
men drained.  Patient  died  two  hours  later.  Post-mortem, 
a  perforated  duodenal  ulcer  found.  General  peritonitis. 
Kidneys  cystic.  (From  notes  kindly  supplied  by  Dr.  Adeline 
Roberts.     Royal  Free  Hospital  Museum.) 

Case  25. — P.  S  ,  aged  twenty-five.  Complained  for 
two  mouths  of  paroxysms  of  dyspnoea,  occasional  mistiness 
of  vision,  digestive  troubles,  and  frequent  vomiting.  There 
was  some  emphysema  of  the  lungs  and  the  heart  sounds  were 
muffled.  The  liver  edge  was  slightly  below  the  costal  margin. 
There  was  no  ascites,  but  -mile  ( edema  of  the  legs.      The  urine 


66  Duodenal  Ulcer 

contained  albumen  and  no  sugar.  The  patient  has  a  bron- 
ehitic  crisis,  but  recovered  under  treatment.  Two  days 
before  death  the  patient  developed  diarrhoea,  for  which 
rectal  examination  revealed  no  cause;  death  from  uraemic 
coma.  At  the  autopsy  there  were  cerebral  softening,  oedema 
and  emphysema  of  the  lungs,  atheroma  of  the  arteries,  hyper- 
trophy of  the  left  ventricle.  First  part  of  the  small  intestine 
contained  bile  and  blood;  mucous  membrane  was  congested 
and  coated  with  viscid  mucus.  The  colon  was  filled  with 
black  blood.  In  the  first  part  of  the  duodenum,  2  cm.  from 
the  pylorus,  was  a  punched-out  ulcer,  around  which  mucous 
membrane  was  inflamed.  The  size  of  the  ulcer  was  about  1.5 
cm.  There  was  no  thickening  or  exudation  on  the  peritoneal 
surface  of  the  duodenum.  There  was  a  second  small  ulcer, 
about  Y2  cm.  in  diameter,  quite  shallow,  in  the  second  part  of 
the  duodenum.  At  a  point  about  8  cm.  below  the  ampulla  of 
Vater  were  two  still  smaller  ulcerations,  clean-cut,  circular, 
and  showing  no  haemorrhage.  Kidneys  weighed,  one  28  and 
one  30  grams,  were  granular  on  the  surface,  and  cirrhotic. 
Histological  examination  of  the  large  ulcer  shewed  normal 
peritoneum,  epithelium  thickened  at  the  edge  of  the  ulcer, 
with  some  necrosis.  The  floor  of  the  ulcer  was  formed  of 
fibrous  tissue,  more  cellular  near  the  intestinal  surface.  There 
was  some  interstitial  haemorrhage.  No  muscular  tissue  was 
seen  at  the  level  of  the  ulcer.  Kidneys  shewed  typical  inter- 
stitial nephritis.  (Barie  and  Delaunay,  "Bull.  Soc.  Med.  des 
Hopitaux,"  1903,  xx,  45.) 

(ask  26. — A  specimen  in  the  Museum  of  the  Royal  Col- 
lege of  Surgeons  of  England.  No.  2430a.  The  first  portion 
of  the  duodenum  with  the  adjacent  end  of  the  stomach  laid 
open  to  display  an  oblong  ulcer  in  the  former.  It  is  situated 
an  inch  beyond  the  pylorus,  and  measures  nearly  an  inch  in 
its  chief  diameter,  which  is  transverse.  The  margin  of  the 
ulcer  is  thickened  and  undermined,  while  its  base  is  loosely 
attached  to  the  subjacent  head  of  the  pancreas.  A  vertical 
section  shews  that  the  common  bile-duct  is  in  close  relation 
with  the  floor  of  the  ulcer.  A  blue  rod  marks  the  course  of 
the  duct.  Close  to  the  pyloric  ring  the  depressed  scars  of 
two  healed  duodenal  ulcers  may' be  seen.     From  a  boy  aged 


Uraemic  Ulcer  of  the  Duodenum  67 

seventeen,  who  was  admitted  for  nephritis  and  anasarca. 
He  died  of  uraemia  five  months  after  the  onset  of  his  illness, 
having  previously  enjoyed  very  good  health.  (Presented  by 
Guy's  Hospital,  1893.) 

Case  27. — D ,  December  3,  1903;  female,  aged  thirty- 
eight.  Has  had  symptoms  on  and  off  for  ten  years;  worse 
of  late.  Vomiting,  pain  in  left  side,  and  nausea.  The  pain 
is  always  present,  but  worse  after  food.  Vomiting  makes 
the  pain  worse.  The  patient  says  she  has  vomited  a  little 
blood  sometimes.  Bowels  constipated.  Loss  of  weight. 
Now  5  st.  4I4  lbs.  P.  C:  Frequent  vomiting.  Tenderness 
over  left  hypochondrium.  Free  HC1  in  stomach  contents 
after  test  meals.  Urine  acid,  specific  gravity  1018,  albumen. 
No  sugar.  At  the  operation  nothing  abnormal  found.  No 
scars.  Posterior  gastroenterostomy.  The  patient  died  De- 
cember 8th.  She  was  sent  by  Dr.  Woodcock,  Leeds.  The 
patient  developed  haematuria  and  uraemie  symptoms  and  died. 
Post-mortem  report:  "No  peritonitis,  union  quite  sound. 
Kidneys  are  small  and  present  cysts  on  their  surfaces.  The 
capsule  does  not  strip  readily,  being  adherent  in  some  places. 
On  passing  the  finger  over  the  surface  of  the  kidney,  a  dis- 
tinctly granular  impression  is  imparted  to  it.  The  cortex  is 
extremely  narrow,  almost  all  the  kidney  substance  being  made 
up  of  the  pyramids.  The  pelves  appear  normal."  There 
was  ulceration  without  induration  in  the  duodenum,  probably 
uraemic  in  origin. 


CHAPTER  IV 
TUBERCULOUS  ULCERATION  OF  THE  DUODENUM 

In  cases  of  miliary  tuberculosis  scattered  deposits  may 
be  found  in  the  duodenum,  as  elsewhere  in  the  body, 
and  in  some  cases  small  superficial  erosions  of  the  mucous 
membrane,  single  or  multiple,  are  present.     They  are  of 


Fit,.  17. — Tuberculous  Ulceration. 
A  portion  of  the  duodenum  shewing  tuberculous  ulceration.  The  ulcer 
is  irregularly  oval,  one  inch  long  by  one-fourth  inch  broad,  with  the  long 
axis  running  transversely  to  the  gut.  The  base  is  uneven  and  the  peritoneal 
surface  at  that  part  is  infiltrated  with  small  nodules.  (London  Hospital 
Museum,  Specimen  No.  1 154  ) 

no  clinical  significance,  being  merely  a  part  of  that 
universal  deposit  of  tubercle  which  is  found  in  the  ter- 
minal stages  of  thoracic  or  abdominal  phthisis.  But 
there  are  cases,  very  few  in  number,  in  which  the  symp- 

68 


Tuberculous  Ulceration  of  the  Duodenum     69 

toms  of  chronic  ulcer  of  the  duodenum  call  for  an  oper- 
ation, when  the  lesion  disclosed  in  the  intestine  is  plainly 
seen  to  be  tuberculous  in  character.  Two  well-marked 
and  indisputable  cases  have  occurred  in  my  own  practice. 


Fig.  18. — Tuberculous  Ulcer  of  the  Duodenum. 

Close  to  the  pyloric  valve  is  an  irregular,  circular  ulcer,  with  raised, 
puckered  edges,  the  size  of  a  crown  piece.  All  the  coats  of  the  bowel  have 
been  eaten  away, and  the  floor  of  the  ulcer  is  formed  by  the  pancreas.  An 
artery  of  considerable  size  crosses  it  for  a  space  of  three-fourths  of  an  inch; 
other  smaller  arteries  with  plugged  orifices  ire  seen  to  form  little  prom- 
inences. 

From  a  man,  aged  forty-nine,  who  died  in  tin-  hospital  May  20,  1868. 
For  two  years  previously  he  had  been  liable  to  repeated  attacks  of  ha'inat- 
emesis  and  had  suffered  from  con-taut  pain  below  the  righl  rili-.  lie  died 
with  rapid  development  of  tubercle  in  his  lungs.  Reported  by  Dr.  Murchi- 
son  in  "Pathological  Societies  Transactions,"  vol.  \\.  p.  1  74.  (Middlesex 
I  [ospital  Museum,  No.  1  1 

and  there  .ire  three  others  in  which  there  was  a  proba- 
bility that  the  ulcer  was  tuberculous.  The  two  cases 
illustrate  very  differenl  types.  In  the  one  type  the 
patienl  is  obviously  the  h<>-i  of  a  tuberculous  deposit; 


7° 


Duodenal  Ulcer 


Fig.  19. — Tuberculous  Ulcers  of  the  Duodenum. 

Three  circular  ulcers  are  present  in  the  specimen.  Two  of  these  have 
led  to  perforation,  the  peritoneum  over  one  of  them  being  considerably 
thickened.  The  base  of  the  third  ulcer  is  formed  by  the  muscular  coat. 
The  edges  of  the  ulcers  are  bevelled  and  shelving  and  appear  as  if  punched- 
out.     They  are  considerably  indurated. 

C.  X.,  aged  thirty-one,  was  admitted  into  the  hospital  under  Dr.  Sturges 
on  October  2,  1884.  The  patient  was  suffering  from  pulmonary  phthisis, 
of  which  he  died  in  a  few  days.  At  the  post-mortem  examination  the  ab- 
dominal cavity  was  found  filled  with  a  puriform  fluid  and  there  was  acute 
patchy  peritonitis.  The  stomach  was  in  a  condition  of  acute  catarrh. 
There  was  a  superficial  ulcer  of  the  mucous  membrane  of  the  csecum.  The 
abdominal  glands  were  enlarged,  especially  near  the  duodenum.  Both 
lungs  were  riddled  with  cavities  and  microscopic  examination  demonstrated 
the  presence  of  the  bacillus  tuberculosis.  (Westminster  Hospital  Museum, 
No.  454.) 


Tuberculous  Ulceration  of  the  Duodenum     71 

he  has  the  hectic  flush,  the  lean  and  shrunken  features, 
the  pinched  appearance  of  the  phthisical  patient.  An 
examination  of  the  chest  reveals  the  evidences,  acute  or 
ancient,  of  consumption.  The  abdomen  shews  a  dilated 
and  perhaps  hypertrophied  stomach,  and  waves  of  con- 


Fic.  20. — Tuberculous  Ulceration  of  the  Duodenum. 

Pylorus  and  upper  portion  of  the  duodenum  shewing  t  wo  ulcers.  About 
the  centre  of  the-  specimen  is  a  small,  oval  ulcer  with  thickened,  indurated 
Its  long  axis  i>  directed  across  the  gut.  Haemorrhage  has  taken 
place  into  its  base.  A  similar  smaller  ulcer  is  seen  hit  ween  it  and  the 
pylorus.  The  large  and  small  intestines  were  both  the  seal  of  extensive 
ulceration.  From  a  man,  aet.  twenty,  who  died  of  pulmonary  phthisis. 
(Royal  Free  Hospital,  No.  87.) 

traction  arc  seen  on  gentle  inflation  of  the  stomach.  A 
swelling  in  or  near  the  pylorus  may  be  present,  or  a 
ma--  may  be  felt  in  the  caTiim.  An  enquiry  into  the 
anamnesis  elicits  a  history  of  long-standing  "dyspepsia," 
and   the  symptoms  of  duodenal   ulcer  may  be  clearly 


72 


Duodenal  Ulcer 


described.  In  such  cases,  especially  if  tuberculous 
deposits  in  the  chest  are  absent  or  quiescent,  the  patient's 
wasted  condition  and  ill  health  may  seem  to  be  largely 
dependent    upon    the    mechanical    obstruction    at    the 


Fig.  21. — Tuberculous  Ulcer  of  the  Duodenum. 

Immediately  beyond  the  pylorus  are  four  irregularly  shaped  ulcers  with 
raised,  indurated  margins  and  deeply  excavated  bases.  One  of  them  has 
perforated  the  intestine,  with  the  exception  of  the  peritoneal  coat.  The 
pancreas  is  firmly  fixed  to  the  gut  by  strong  adhesions. 

From  a  man,  aged  forty-nine,  who  died  of  pulmonary  mischief  of  long 
standing.  Xo  symptoms  pointing  to  the  condition  of  the  duodenum  were 
noticed  during  the  time  he  was  in  the  hospital. 

(See  account  of  case  by  Dr.  Moore,  in  the  "  Pathological  Societies  Trans- 
actions," vol.  xxxiv.     St.  Barth.  Hosp.  Museum,  No.  1966a.) 


outlet  of  the  stomach,  and  surgical  treatment  may  be 
considered  necessary.  In  case  112  in  my  own  series  we 
knew  of  the  existence  of  old  and  not  very  active  tubercle 
in  the  chest,  and  it  was  probable  that  tuberculous  peri- 


Tuberculous  Ulceration  of  the   Duodenum     73 

tonitis  beginning  in  the  appendix,  or  possibly  in  a  duo- 
denal ulcer,  was  present.  Yet  because  of  the  severe, 
wearing  pain  of  indigestion  and  the  consequent  malnu- 


Fig.  22. — Tuberculous  Ulceration  of  the  Duodenum. 

A  portion  of  the  first  part  of  a  duodenum,  shewing  a  small,  rounded 
ulcer  with  thickened  edges,  situated  half  an  inch  from  the  pylorus.  The 
base  of  the  ulcer  is  formed  by  the  muscular  coat  of  the  bowel,  and  miliary 
tubercles  are  visible  beneath  the  peritoneum.  Below  is  mounted  a  small 
piece  of  the  ileum,  exhibiting  a  well-marked  tuberculous  ulcer. 

Stephen  W..  .h.  twenty-six,  was  admitted  under  Dr.  Brighl  in  [837 
for  chronic  phthisis.  At  the  autopsy  there  were  numerous  ulcer-  through- 
out the  intestines  and  the  mesenteric  glands  were  caseous.  (Guy's  Hosp. 
Museum,  No.  747.) 

trition  I  thought  it  righl  to  advise  operation  and  to 
perform  gastro-enterostomy  for  a  large  tuberculous 
mass  in  the  duodenum,  which  had  started  in  a  chronic 
nicer,  and  had  caused  a  high  degree  of  stenosis. 


74  Duodenal  Ulcer 

In  the  second  type,  well  illustrated  by  a  case  operated 
upon  in  May,  1909,  the  patient  gave  a  clear  history  of 
duodenal  ulcer,  and  at  the  operation  it  was  found  that 
the  ulcer  was  plainly  tuberculous;  scattered  deposits 
of  tubercle  were  found  in  all  the  parts  around  the  ulcer. 
The  following  are  the  notes  of  the  case: 

G.  B.,  male,  aged  forty-nine,  sent  by  Dr.  Blair,  Helmsley. 
The  patient  lias  suffered  for  eight  to  ten  years  from  indiges- 
tion. The  attacks  came  on  every  few  months,  and  were 
always  worse  between  November  and  March.  During  the 
last  winter  has  suffered  more  than  ever.  Pain  usually  comes 
two  hours  after  a  meal;  but  if  heavy  food  is  taken,  pain 
comes  in  one  to  one  and  a  half  hours.  It  is  felt  in  the  epi- 
gastric and  right  hypogastric  regions.  The  pain  usually 
lasts  until  the  next  meal  or  until  something  is  taken;  brandy 
and  water,  rum,  or  tea  and  bread  and  butter  give  most  relief. 
On  April  3d  last,  two  hours  after  tea,  had  a  sudden  very  severe 
attack  of  pain,  which  prostrated  him.  He  vomited  several 
times.  The  pain  lasted  for  a  fortnight  and  all  the  upper  part 
of  the  body  was  very  tender.  Since  then  has  lost  7  lbs.  in 
weight,  and  has  been  unable  to  take  any  food  without  pain 
coming  on  in  a  few  minutes.  Operation  May  10,  1909.  A 
large  duodenal  ulcer  was  found  adherent  to  the  under  surface 
of  the  liver;  it  had  evidently  undergone  a  "subacute"  per- 
foration. Scattered  all  around  it,  more  densely  in  the  edges, 
were  a  number  of  typical  miliary  tubercles  (one  was  excised 
and  examined).  The  ulcer  felt  very  hard  and  indurated  and 
its  margin  was  thick  and  raised  and  contained  many  tuberculous 
nodules.  The  small  intestine  and  appendix  were  examined, 
but  no  other  tuberculous  deposit  was  found.  The  patient 
made  a  good  recovery.  A  week  after  operation  he  was  thor- 
oughly examined,  but  no  evidence  of  tuberculosis  could  be 
discovered.     The  patient  was  quite  well  in  November,  191 1. 

It  is,  of  course,  well  known  that  tuberculous  ulcers 
are  found  most  commonly  in  the  lower  end  of  the  ileum, 


Tuberculous  Ulceration  of  the   Duodenum     75 

and  that  they  become  less  frequent  higher  in  the  intes- 
tine; in  the  duodenum  they  are  certainly  rare.  In  the 
vast  majority  of  cases  there  can  be  no  doubt  that  the 
tuberculous  ulcer  is  secondary  to  an  infection  in  the 
lungs.  Sir  Andrew  Clark  and  Dr.  Murchison,  however, 
both  consider  that  in  cases  reported  by  them  the  ulcer 
was  primary,  and  had  opened  the  portals  of  infection 
for  a  generalised  tuberculosis.  In  one  case  in  my  serie^ 
(Xo.  127),  not  recognised  at  the  time  as  being  tubercu- 
lous,  phthisis,  developed  subsequently. 

The  following  is  a  complete  list  of  all  recorded  cases 
of  tuberculous  ulcer  of  the  duodenum: 


DUODENAL  ULCERS  ASSOCIATED  WITH  TUBERCULOSIS 

Case  i. — Tuberculous  ulcer  of  the  duodenum:  James 
X—  -  was  admitted  under  Dr.  Bright  in  1827  for  phthisis, 
from  which  he  died.  At  the  autopsy  a  small  ulcer  was  found 
at  the  commencement  of  the  duodenum,  and  there  were  main 
of  larger  size  pretty  thickly  sprinkled  throughout  both  the 
small  and  large  intestines.  Their  edges  were  irregular  and 
slightly  elevated,  and  the  ulceration  "appeared  to  attend  on 
the  softening  of  tuberculous  material."  (Perry  and  Shaw. 
( !ase  62.) 

Case  2. — Tuberculous  ulcer  of  the  duodenum:  Stephen 
W—  .  .11.  twenty-six,  was  admitted  under  Dr.  Bright  in 
1837  for  chronic  phthisis.  At  the  autopsy  there  were  num- 
erous ulcers  throughout  the  intestine  and  the  mesenteric 
gland-  were  caseous.  In  the  first  part  of  the  duodenum, 
halt  an  inch  from  the  pylorus,  was  .1  small  rounded  ulcer  with 
thickened  edges;  the  base  of  the  ulcer  was  formed  by  the 
muscular  coal  of  the  bowel,  and  miliary  tubercle-  were  visible 

beneath  its  serous  invest  meat  .      |  Perry  and  Shaw  ,  (  'ase  63.  1 

CASE  3.  Tuberculous  ulcer  of  stomach  and  duodenum. 
Duodenum   contained   a   small    ulcer   near   the   pylorus,   asso 


76  Duodenal  Ulcer 

ciated  with  similar  ulcers  in  the  jejunum  and  stomach,  in  a 
case  of  phthisis.     (Perry  and  Shaw,  Case  64.) 

(  ase  4. — Tuberculous  ulceration  of  the  duodenum;    ascaris 

lumbricoides:    Mary  G ,  set.  three,  was  admitted  under 

Dr.  Hughes  for  diarrhoea  of  three  months'  duration.  Occa- 
sionally there  was  blood  in  the  motions.  Various  remedies 
for  the  diarrhoea  were  tried,  but  the  child  became  emaciated 
and  died  seven  weeks  after  her  admission.  At  the  autopsy 
there  were  numerous  tubercles  in  the  lung  and  caseous  ab- 
scesses in  the  liver.  The  duodenum  contained  a  lumbricus 
teres,  and  the  lower  portion  displayed  some  distinct  ulceration. 
The  caecum  and  colon  were  ulcerated  and  the  mesenteric  glands 
caseous.     (Perry  and  Shaw,  Case  66.) 

Case  5. — Tuberculous  ulcer  of  duodenum:    Louisa  C , 

aet.  thirty,  was  admitted  under  Dr.  Pavy  for  phthisis,  from 
which  she  died.  Shortly  after  her  admission  she  became 
maniacal  and  had  epileptic  seizures.  At  the  autopsy  an 
exostosis  was  found  growing  from  the  inner  surface  of  the 
frontal  bone  on  the  right  side,  pressing  upon  and  indent- 
ing the  second  frontal  convolution.  There  were  numerous 
tuberculous  vomicae  in  the  lungs  and  a  few  ulcers  in  the  duo- 
denum. The  jejunum,  ileum,  and  caecum  were  also  affected 
by  ulceration.  The  mesenteric  glands  were  large  and  caseous. 
(Perry  and  Shaw,  Case  67.) 

Case  6. — Tuberculous  ulcer  of  the  duodenum:   John  R , 

aet.  eleven,  was  admitted  under  Dr.  Wilks  with  signs  of  phthisis. 
Fifteen  weeks  later  he  died,  and  at  the  autopsy  a  caseous  mass 
was  found  in  the  brain  and  the  lungs  contained  numerous 
vomicae  and  tubercles.  The  duodenum  as  well  as  the  small 
and  large  intestines  presented  numerous  ulcers,  varying  in 
size  trom  a  quarter  of  an  inch  in  diameter.  There  were  caseous 
mesenteric  glands.     (Perry  and  Shaw,  Case  68.) 

Case  7. — Tuberculous  ulcer  of  duodenum:     Peter  S , 

aet.  thirty-six,  was  admitted  under  Dr.  Wilks  with  signs  of 
phthisis,  from  which  he  died.  At  the  autopsy  tuberculous 
ulcers  were  found  in  the  duodenum,  jejunum,  ileum,  and  caecum, 
and  a  few  in  the  colon.     (Perry  and  Shaw,  Case  69.) 

Case  8. — Phthisis;     healed   ulcer  in  duodenum:     William 
J ,  aet.  forty-four,  was  admitted  under  Dr.  Cholmeley  in 


Tuberculous  Ulceration  of  the   Duodenum     77 

1 83 1  for  phthisis,  from  which  he  died.  At  the  autopsy 
numerous  vomicae  were  found  in  the  lungs,  and  there  were 
ulcers,  probably  tuberculous,  in  the  small  and  large  intes- 
tines. In  the  duodenum,  near  the  entrance  of  the  ducts, 
which  were  healthy,  there  was  a  slight  but  decided  contrac- 
tion puckering  the  mucous  membrane,  and  arising  from 
hardening  of  the  cellular  membrane  external  to  the  gut,  which 
very  firmly  united  the  pancreas  to  the  same  part.  The  pan- 
creas was  healthy.      (Perry  and  Shaw,  Case  73.) 

Case  9. — Phthisis;  perforating  ulcer  of  the  duodenum: 
George  E ,  aet.  thirty,  was  admitted  into  Guy's  Hospi- 
tal, having  four  months  previously  brought  up  blood.  Just 
before  admission,  whilst  apparently  in  good  health,  he  was 
suddenly  seized  with  abdominal  pain  and  collapse.  Subse- 
quently symptoms  of  peritonitis  supervened,  and  he  died 
fifty-six  hours  from  the  onset  of  his  illness.  At  the  autopsy 
there  was  acute  peritonitis,  and  castor  -oil  was  found  floating 
in  the  abdominal  cavity.  In  the  first  part  of  the  duodenum, 
an  inch  from  the  pylorus,  was  an  ulcer  of  the  size  of  a  shill- 
ing piece,  having  in  its  base  a  circular  opening  one-third 
of  an  inch  in  diameter.  There  were  "aphthous  ulcers"  in 
the  stomach,  two  small  ones  being  covered  with  coagula. 
At  the  apex  of  the  left  lung  was  a  small  phthisical  cavity. 
The  case  is  quoted  by  Dr.  Habershon  in  his  work  on  "Dis- 
eases of  the  Abdomen."     (Perry  and  Shaw,  Case  74.) 

Case  10. — Ulcer  of  duodenum(?),  tuberculous:  James 
M  — ,  set.  sixty-four,  was  admitted  under  Dr.  Hughes  in  a 
prostrate  and  anaemic  condition,  and  died  about  twelve  weeks 
afterwards.  For  many  years  he  had  been  exceedingly  in- 
temperate in  his  habits.  For  a  short  time  before  his  death 
he  suffered  from  cough,  with  dullness  on  the  left  side  of  the 
chest.  Numerous  vomicae  were  found  in  the  lungs.  The 
Stomach  was  large,  and  near  the  pylorus  it  contained  a  small 
excavated  ulcer  about  the  size  and  shape  of  a  fourpenny- 
piece.  There  was  no  external  thickening.  There  was  a 
similar  ulcer  in  the  duodenum  near  the  pylorus.  It  was 
rather  larger  than  that  iii  the  stomach.  The  stomach  was 
submitted  to  microscopic  examination  in  iS()i,  and  shewed  a 
condition  of  acute  gastritis  with   superficial   ulceration.     In 


78  Duodenal  Ulcer 

the  ileum  the  solitary  and  agminated  glands  were  enlarged, 
and  some  were  ulcerated.  There  were  numerous  ulcers  in 
the  caecum  and  the  colon.  These  were  presumably  tubercu- 
lous.    (Perry  and  Shaw,  Case  75.) 

Case   ii. — Peptic  ulcer  in  tuberculosis:    John  E ,  set. 

twenty-six,  was  admitted  under  Dr.  Wilks  with  signs  of 
tuberculous  peritonitis  and  laryngitis.  Two  days  later  he 
died,  and  at  the  autopsy  the  left  kidney  and  ureter,  the 
prostate  and  testes,  were  tuberculous.  There  was  much 
tubercle  in  the  peritoneum  and  in  the  lungs,  and  the  epi- 
glottis was  ulcerated.  The  duodenum  contained  a  large 
quadrilateral  ulcer,  just  beyond  the  pylorus,  three-quarters 
of  an  inch  across.  The  rest  of  the  intestine  wras  healthy. 
(Perry  and  Shaw,  No.  76.) 

Case  12. — Phthisis;  ulcer  of  duodenum;  haemorrhage: 
John  K ,  ast.  forty-four,  wras  admitted  into  St.  Bartholo- 
mew's Hospital  under  Dr.  Roupell,  having  for  the  last  three 
months  suffered  from  haemorrhage  from  the  bowels,  and 
having  vomited  blood  occasionally  in  small  quantities.  He 
died  twelve  days  after  admission,  and  at  the  autopsy  the 
stomach  and  the  rest  of  the  alimentary  canal  were  quite 
healthy,  except  that  just  beyond  the  pylorus  was  a  large 
excavated  ulcer  an  inch  and  a  half  in  diameter,  the  base  of 
which  was  formed  by  the  pancreas.  At  the  time  of  the 
inspection  no  blood  was  found  in  the  intestines,  nor  was  it 
ascertained  from  what  vessel  the  haemorrhage  had  proceeded. 
The  patient  had  passed  very  little  blood  during  his  stay  in 
the  hospital.  There  was  a  cavity  in  the  right  apex  and  tubercle 
in  both  lungs.     (Perry  and  Shaw,  Case  77.) 

Case  13. — Tuberculous  ulcer  of  duodenum;  perforation: 
A  lad,  aet.  eighteen,  was  admitted  into  the  London  Hospital 
under  Sir  Andrew'  Clark  in  a  state  of  collapse,  and  was  though  t 
to  be  suffering  from  retention  of  urine.  Two  days  before 
admission  he  had  played  in  a  cricket  match,  and  on  his  re- 
turn home  felt  sick,  feverish,  and  otherwise  uncomfortable. 
Next  day  he  was  better,  and  after  his  supper  took  a  short 
walk  without  fatigue.  On  the  morning  of  admission  he  was 
seriously  ill,  vomited  frequently,  and  was  seen  by  a  doctor, 
who  found   thai    he  had  passed  no  urine  and  sent  him  into 


Tuberculous  Ulceration  of  the  Duodenum     79 

the  hospital.  On  admission  the  lad  complained  of  nausea 
with  occasional  vomiting,  pain  in  the  right  side  of  the  abdo- 
men, and  shortness  of  breath.  Pressure  in  the  right  hypo- 
chondrium  increased  the  abdominal  pain.  The  bladder  was 
found  to  be  empty.  He  was  ordered  some  brandy  mixture 
and  placed  in  a  warm  bath.  After  fifteen  minutes  he  was 
removed  from  the  bath,  and  whilst  being  dried  by  the  porter 
suddenly  fainted  and  died.  At  the  autopsy  the  peritoneal 
cavity  was  found  to  contain  a  small  quantity  of  grumous 
fluid,  and  there  was  evidence  of  recent  peritonitis.  In  the 
duodenum,  about  an  inch  and  a  half  from  the  pylorus,  was  a 
small  ulcer  about  the  size  of  a  sixpence,  with  thick,  red, 
rounded  margins  and  a  whitish  granular  base,  in  which  there 
was  a  minute  opening  leading  into  the  peritoneal  cavity.  The 
whole  mucous  membrane  of  the  duodenum  was  greatly  con- 
gested. Brunner's  glands  were  enlarged,  and  a  few  of  them, 
stuffed  with  a  cheesy-looking  compound,  were  ulcerated  at 
their  most  projecting  parts.  No  other  disease  was  found  in 
the  abdominal  organs.  There  was  an  ante-mortem  thrombus 
in  the  pulmonary  artery  and  yellow  tubercle  in  the  apex  of  the 
right  lung.  Sir  Andrew  Clark  says:  "To  me  the  order  of 
events  seems  to  have  been  as  follows :  out  of  general  ill  health 
there  arose  in  the  first  place  follicular  disease,  followed  by 
ulceration  of  the  duodenum ;  and  in  the  second,  the  tubercular 
deposits,  most  probably  of  embolic  origin,  in  the  lungs." 
(See  "Cases  of  Duodenal  Perforation,"  by  Sir  Andrew  Clark, 
in  the  "British  Medical  Journal,"  1867,  vol.  i,  p.  687.)  (Perry 
and  Shaw,  Case  78.) 

Cash  14. — Duodenal  ulcer  in  phthisis:  Thomas  P —  .  aet. 
forty-nine,  was  admitted  under  Dr.  Murchison  into  the 
Middlesex  Hospital  for  pain  in  the  right  hypochondriac  region 
and  occasional  severe  attacks  of  haematemesis,  eight  or  nine 
<»f  such  attacks  having  occurred  in  the  space  of  two  years. 
Alter  admission  symptoms  of  phthisis  supervened  and  he  died 
five  weeks  later.  At  the  autopsy  an  ulcer  was  found  in  the 
duodenum,  the  size  of  a  half-crown,  situated  immediately 
beyond  the  pylorus;  the  base  was  formed  by  the  exposed 
pancreas,  ,i!i(l  the  edges  were  thickened  and  indurated.  The 
lymphatic  glands  in  the  neighbourhood  of  this  ulcer  were  en- 


8o  Duodenal  Ulcer 

larged,  sonic  of  them  to  the  size  of  a  pigeon's  egg,  and  there 
was  tuberculous  excavation  of  the  apex  of  the  right  lung,  and 
enlargement  of  the  bronchial  glands.  Dr.  Murchison  thought 
that  this  was  a  case  of  the  development  of  tubercle  as  the  result 
of  inoculation  through  a  simple  ulcer.  (Perry  and  Shaw, 
Case  79.) 

Case   15. — Phthisis;    perforating  ulcer  of  the  duodenum: 

George  G ,  set.  fifty-six,  was  admitted  into  St.  George's 

Hospital  under  Dr.  Barclay  with  intense  abdominal  pain, 
which  was  much  increased  on  pressure,  and  was  referred  to 
the  lower  part  of  the  abdomen,  which  was  flat  and  very  hard. 
He  stated  that  with  the  exception  of  epigastric  pain,  worse 
after  food,  from  which  he  had  suffered  for  the  last  three 
weeks,  he  had  always  had  good  health.  The  pain  had  not 
been  very  severe,  and  had  not  incapacitated  him  from  work. 
On  the  day  of  admission  he  had  taken  bread  and  cheese  for 
dinner  in  the  middle  of  the  day.  The  meal  was  followed  by 
the  usual  slight  epigastric  pain,  and  he  thought  nothing  of  it. 
But  a  little  before  six  o'clock,  whilst  walking  in  the  park,  he 
was  suddenly  attacked  by  extreme  violent  pain  in  the  belly, 
and  was  at  once  brought  to  the  hospital.  Perforation  being 
suspected,  he  was  treated  with  opium,  and  everything  was 
administered  by  the  rectum.  He  died  about  thirty-six  hours 
from  the  onset  of  symptoms,  and  at  the  autopsy  Dr.  Whipham 
found  miliary  tubercle,  and  excess  of  fibrous  tissue  at  the  apex 
of  the  right  lung.  There  was  atheroma  with  dilatation  of  the 
arch  of  the  aorta.  Turbid  yellow  fluid  and  much  recent  lymph 
were  found  in  the  peritoneum.  In  the  first  portion  of  the 
duodenum,  a  little  beyond  the  pylorus,  and  on  the  anterior  sur- 
face, was  a  rounded  perforation  with  clean-cut  edges,  a  little 
larger  than  a  pea.  On  laying  open  the  gut  this  was  found  to 
have  been  caused  by  a  small,  thin-edged  ulcer,  the  diameter  of 
which  was  a  little  greater  than  that  of  the  perforation.  No 
other  ulcer  existed.     (Perry  and  Shaw,  Case  80.) 

Case  16. — Phthisis;  perforating  ulcer  of  the  duodenum: 
Dr.  Hebb,  in  his  paper  on  "Two  cases  of  perforating  ulcer 
of  the  duodenum"  in  the  "Westminster  Hospital  Reports," 
vol.  vii,  p.  84,  refers  to  the  case  of  a  male,  a>t.  thirty-one, 
who   was   admitted    under    Dr.   Sturges,   and   died   next   day 


Tuberculous  Ulceration  of  the   Duodenum     81 

from  peritonitis.  At  the  post-mortem  examination  a  large 
perforating  ulcer  of  the  duodenum  was  found,  but  there  was 
also  a  very  advanced  phthisis,  "to  which,  had  he  not  been 
carried  off  by  the  perforating  ulcer,  he  must  have  succumbed 
very  shortly."     (Perry  and  Shaw,  Case  81.) 

(  A.SE  17. — (The  following  case  is  No.  <S  in  Trier's  mono- 
graph.) M.,  iet.  fifty-one.  Seven  years'  history  of  pain 
after  food,  coming  on  within  three  or  four  hours.  Pain  was 
to  the  right  of  the  umbilicus  and  a  little  above.  Had  haem- 
atemesis  once,  severely.  Bowels  constipated.  Attacks  of 
this  type  would  come  on  at  intervals.  Wasting  marked. 
Skin  yellowish  .and  dark.  Atrophic  and  wrinkled.  Scle- 
roses dirty  yellow.  Thought  to  be  typically  cancerous  in 
appearance,  probably  secondary  to  ulcer.  Abdomen  prom- 
inent at  and  below  umbilicus.  Visible  peristalsis  from  left 
to  right.  A  visible  tumour  appeared  in  epigastrium,  not 
adherent  to  abdominal  wall,  1  to  2  inches  in  circumference. 
There  was  tenderness  here  also.  In  November  he  died 
following  a  severe  attack  of  ha?matemesis,  with  violent  ab- 
dominal pain  lasting  two  days.  Post-mortem:  Obsolete 
tubercles  in  both  lung  apices.  Stomach  much  dilated,  py- 
lorus and  first  part  of  duodenum  firmly  fixed  to  pancreas, 
which  was  twice  the  normal  size  and  very  hard.  Xo  changes 
in  stomach.  In  the  duodenum,  close  to  the  pylorus,  was  a 
circular  opening  leading  into  a  cavity  the  size  of  half  a  walnut, 
the  bottom  of  the  cavity  being  formed  by  the  pancreas. 
The  lumen  here  was  1  of  an  inch  and  was  filled  in  by  a 
thrombus. 

Case  iX. — (The  following  is  case  38  in  Krauss's  nn mo- 
graph.)  Duodenal  ulcer  (perforating)  in  case  of  tubercu- 
losis of  lung>  and  intestine.  Case  related  to  the  author  by 
Dr.  Elsasser,  of  Stuttgart:  Mr.  R.,  bookkeeper,  aet.  fifty, 
had  suffered  for  some  time  from  pulmonary  and  intestinal 
tuberculosis.  A  l<u  week-  preceding  death  he  experienced 
an  uncomfortable  sensation  in  the  abdomen  after  taking 
small  quantities  ol  food  and  drink.  The  pain  commenced 
in  the  stomach  and  spread  over  the  whole  abdomen,  termi- 
nating in  a  colicky  exacerbation.  Mad  several  attacks  ol 
intestinal  haemorrhage;  much  reduced  l>\  his  illness;  signs 
6 


82  Duodenal  Ulcer 

of  a  diffuse  peritonitis  commencing  in  the  right  iliac  region 
supervened,  which  proved  fatal  in  a  few  days.  On  section 
both  lungs  shewed  extensive  caseation;  cavity  as  large  as  a 
hen's  egg  in  the  right  upper  lobe.  In  the  intestine  there 
were  four  perforations,  one  in  the  caecum  as  large  as  a  dollar, 
two  others  in  the  ileum,  all  due  to  tuberculous  ulceration. 
The  fourth  perforation  was  quite  different  from  the  others. 
It  appeared,  newly  formed,  situated  in  the  duodenum,  about 
i  inch  below  the  pylorus.  There  was  no  swelling  of  the 
mucous  membrane.  The  remainder  of  the  duodenum  was 
normal.     The  jejunum  was  also  free  from  ulceration. 

Case  19. — M.,  aged  thirty-three.  Double  pulmonary 
tuberculosis;  hypertrophic  cirrhosis  with  ascites.  Diges- 
tion good.  No  abdominal  pain.  Discomfort  and  painful 
respiration  owing  to  ascites  and  oedema.  Post-mortem: 
Tuberculous  cavities  at  both  apices;  double  pleural  effusion. 
Stomach  normal.  Peritoneum  shewed  whitish  granulations, 
disseminated  especially  over  intestines  and  gastro-hepatic 
omentum.  Mesenteric  glands  very  large  and  indurated. 
Less  than  1  cm.  from  the  pylorus  a  duodenal  ulcer — a  large 
ulcer  elongated  in  the  long  axis  of  the  bowel.  Below  this 
several  smaller  ulcers;  in  all,  there  were  seven  ulcers  in  the 
first  part  of  the  duodenum.  Perforation  in  the  largest  ulcer 
seemed  imminent,  the  base  being  formed  of  serosa  only. 
Four  ulcers  were  found  in  the  jejuno-ileum.  (Claude,  "Bull. 
Soc.  Anat.  de  Paris,"  1896,  lxxi,  230.) 

Case  20. — A.  R.,  male,  aet.  thirty-six.  For  five  years  had 
suffered  from  pain  and  vomiting  after  eating.  Pain  came 
soon  after  taking  food,  and  on  three  occasions  there  were 
very  severe  attacks  of  abdominal  cramp,  "as  if  the  intestines 
were  twisted  or  knotted."  Death  occurred  in  collapse  and 
delirium.  At  the  post-mortem  many  tuberculous  ulcers  were 
found  in  the  duodenum  and  throughout  the  entire  length  of 
the  small  intestine.  The  lungs  were  infiltrated  with  tubercles 
and  the  mesenteric  glands  were  cheesy.  (Satterthwaite, 
"Med.  Record,"  New  York,  1900,  lvii,  485.) 

Case  21. — G.  H.,  male,  aged  twenty,  admitted  with  late 
phthisis;  had  hectic  and  night-sweats  and  chronic  diarrhoea, 
and   died   of   gradual   exhaustion.     The   bowel   was   studded 


Tuberculous  Ulceration  of  the   Duodenum     83 

with  ulcers  from  the  duodenum  to  the  caecum.  (Satter- 
thwaite,  "Med.  Rec,"  X.  V.,  1900,  Ivii,  485.) 

Cases  22  and  23. — Recorded  by  Francine  ("Amer.  Jour. 
Med.  Sci.,"  1905,  cxxix,  429).  The  ulcers  were  discovered  at 
autopsy;    few  details  are  given. 

Case  24. — S.  West  ("Diseases  of  the  Organs  of  Respira- 
tion," second  edition,  1909,  ii,  437)  relates  one  case  of  phthisis 
in  which  two  small  ulcers  were  found  in  the  duodenum; 
perforation  of  one  of  them  had  caused  death. 

Case  25. — J.  S.,  aged  twenty  years,  a  stone-grinder,  who 
had  a  slight  family  history  of  phthisis.  In  childhood  patient 
had  hip-joint  disease  and  enlarged  glands  in  the  neck,  which 
suppurated.  Suffered  for  some  years  from  cough,  shortness 
of  breath,  night-sweats,  emaciation,  and  haemoptysis.  Both 
lungs  were  extensively  affected.  The  glands  round  the  trachea 
were  enlarged  and  cheesy.  There  was  extensive  ulceration 
of  the  intestine  and  one  small  ulcer  in  the  larynx  at  the  base 
of  the  left  vocal  cord.  (From  notes  supplied  by  the  Registrar, 
Royal  Free  Hospital,  London.) 

There  are  two  specimens  of  tuberculous  ulcer  in  the 
Museum  of  the  Westminster  Hospital: 

Case  26. — (Specimen  454.)  C-  — ,  aged  thirty-one,  was 
admitted  into  the  hospital  under  Dr.  Sturges  on  October 
2,  1884.  The  patient  was  suffering  from  pulmonary  phthisis, 
of  which  he  died  in  a  few  days.  At  the  post-mortem  examina- 
tion the  abdominal  cavity  was  found  filled  with  a  puriform 
fluid  and  there  was  acute  patchy  peritonitis.  The  stomach 
was  in  a  condition  of  aeute  catarrh.  There  was  a  superficial 
ulcer  of  the  mucous  membrane  of  the  ileo-ca-cal  valve,  and 
acute  inflammation  of  the  mucous  membrane  of  the  caecum. 
The  abdominal  glands  were  enlarged,  especially  near  the 
duodenum.      Both     lungs     were     riddled     with     cavities,     and 

microscopic  examination  demonstrated  the  presence  of  the 
tubercle  bacillus.  In  the  duodenum  were  three  circular  ulcer-.. 
Two  of  these  had  led  to  perforation,  the  peritoneum  over  one 
of  them  being  considerably  thickened.      The  base  of  the  third 


84  Duodenal  Ulcer 

ulcer  was  formed  by  the  muscular  coat.  The  edges  of  the 
ulcers  are  beveled  and  shelving  and  appear  as  if  punched  out. 
They  arc  considerably  indurated. 

Case  27. — (Specimen  454a.)  E.  H.,  aet.  twenty-nine, 
had  been  well  until  six  months  before  admission,  when  she 
began  to  suffer  with  pain  on  defalcation;  she  attended  at  St. 
George's  Hospital  and  was  there  operated  upon  for  fistula. 
She  was  discharged  before  the  wound  healed  and  was  advised 
to  go  to  a  warmer  climate.  The  family  history  was  phthisical, 
and  when  admitted  to  the  Western  Hospital,  on  July  9,  1894, 
the  patient  was  suffering  from  active  phthisis,  and  w-as  too  ill 
for  operation,  dying  on  July  27th.  Post-mortem  examination : 
All  lymphatic  glands  were  large,  caseous,  and  tubercular. 
The  lungs  were  the  seat  of  vomicae  and  fibro-caseous  tubercles. 
The  gastric  and  intestinal  mucosae  displayed  tuberculous 
ulceration,  and  tubercle  was  also  present  in  the  liver,  spleen, 
and  kidneys.  The  gastric  and  duodenal  mucosae  were  studded 
with  small,  punched-out,  tuberculous  ulcers,  which  are  es- 
pecially numerous  towards  the  fundus.  They  vary  in  size 
from  that  of  a  pin's  head  to  that  of  a  three-penny  piece. 

Cases  28,  29,  30,  31,  32,  33. — The  specimens  of  these  cases 
are  in  the  museums  of  the  various  London  hospitals.  Photo- 
graphs are  here  reproduced. 

Case  34. — Preparation  1594,  in  the  museum  of  the  Royal 
College  of  Surgeons  of  Edinburgh,  shews  tuberculous  ulcers  in 
the  duodenum,  jejunum,  and  ileum. 

CASES  35-41. — In  Krug's  Thesis  (Kiel,  1900)  it  is  stated  that 
in  the  post-mortem  room  at  Kiel,  in  years  1 873-1 899,  there  were 
53  cases  in  which  'duodenal  ulcers  or  scars  were  found;  of 
these  seven  were  tuberculous,  four-  in  men,  three  in  women. 
The  briefest  details  are  given  in  a  table  at  the  end  of  the  pam- 
phlet. 


CHAPTER   V 
MELJENA  NEONATORUM  AND  DUODENAL  ULCER 

Hemorrhage  from  the  alimentary  tract  of  the  new- 
born occurring  as  haematemesis  or  melaena  would  appear 
to  be  not  very  infrequent,  if  we  are  to  judge  from  the 
reports  of  maternity  hospitals  at  home  and  abroad. 
In  a  very  small  proportion  of  the  fatal  cases  an  exami- 
nation of  the  parts  reveals  the  presence  of  one  or  more 
ulcers  in  the  duodenum.  This  may  be  the  only  part  of 
the  alimentary  canal  in  which  a  lesion  is  recognisable, 
or  there  may  be  haemorrhagic  infarcts  or  ulcers  in  the 
stomach,  small  or  large  intestine.  With  regard  to  the 
frequency  of  melaena  neonatorum  the  following  statistics 
arc  given  by  Shukowsky  ("Archiv.  f.  Kinderheilk.." 
1907,  xlv,  321):  Rilliet  published  one  case  only;  Baillard, 
15;  Henoch  in  thirty-eight  years  saw  14  cases;  Kling 
in  12,000  births  observed  17  rases;  Hecker,  8  in  4000; 
Silbermann,  37  in  29,333;  Lederer,  8  cases;  Carans, 
1  in  191 1  ;  Hergott,  2  in  3000;  Crunch,  1  in  2900; 
Spiegelberg,  1  in  2500.  Taking  these  and  other  smaller 
figures,  and  including  his  own,  he  considers  that  melaena 
occurs  in  not  more  than  1  to  1000  live-births.  In  a  \er\ 
-m. ill  proportion  only  of  these  is  the  haemorrhage  due 
to  .in   ulcer  (il    t  lie  duodenum. 

\   reference   t<»  the  cases  recorded   below    will   -hew 
thai  in  some  instances  haemorrhage  come-  within  a  tew 


86 


Duodenal  Ulcer 


hours  of  birth  and  rapidly  proves  fatal,  whereas  in 
others  the  onset  of  copious  bleeding  may  occur  only 
after  a  tedious  and  wasting  illness  characterised  by  a 
marked  anaemia.  Helmholz  ("  Deut.  med.  Woch.,"  1909, 
i,  534),  in  an  excellent  article,  states  his  belief  that 
dtiodenal  ulcer  in  late  infancy  is  by  no  means  so  infre- 
quent as  has  been  supposed,    and    that  its  discovery  is 


I  Multiple 

j  ulcers 


Perforation  of  ulcer  just 
beyond  pylorus 


ylorus 


Fig.  23. — Multiple  Ulcers  in  the  Duodenum  of  an  Infant  Six  Weeks 
Old.     (Case  4  in  Helmholz's  list.) 

so  bound  up  with  an  antecedent  wasting  illness  that 
some  connexion  must  exist  between  them.  In  some  of 
the  earlier  recorded  cases  there  have  been  examples  of 
extreme  wasting,  but  this  was  held  to  be  due  to  cicatricial 
changes  in  the  ulcer  causing  duodenal  obstruction  and 
vomiting.  Helmholz  is  of  the  opinion  that  the  enfeebled, 
wasting  infant  falls  an  easy  victim  to   the  disease,  the 


Melaena  Neonatorum  and  Duodenal  Ulcer     87 

peptic  ulcer  of  the  duodenum  being  then  developed  more 
readily  than  in  a  healthy  child.  He  then  relates  that  in 
16  cases  of  "  Padatrophie"  coming  to  autopsy  there 
were  no  less  than  8  in  which  an  ulcer  was  discovered. 
The  cause  of  the  onset  of  the  lesion  in  early  infancy 
has  been  much  discussed.  Landau  ("  Ueber  Melsena  der 
Xeugeborenen,"  etc.,   Breslau,   1874)   believed  that  the 


Pylorus 
Ulcer 


*~V"_^I___  Papilla  of  Yater 


Fig.  24. — Large  Ulcer  of   Duodenum.     (Case  7  in   Helmholz's  list.) 
The  patient  was  lour  months  old. 


incidence  was  due  to  thrombosis  of  the  umbilical  vein; 
thrombi  were  carried  thence  into  the  general  circulation, 
and  were  deposited  in  various  organs.  In  the  duodenum 
an  infarct  formed,  and  the  removal  of  the  dead  area  SO 
resulting  left  an  open  ulcer  in  the  bowel.  With  few 
exceptions  this  view  has  commended  itself  to  later 
writers,  and  Helmholz  thus  summarises  the  matter: 
"The  typical  duodenal  ulcer  came  into  being  through  a 


88  Duodenal  Ulcer 

local  necrosis  of  the  intestinal  wall  which  was  caused 
by  a  thrombosis  of  the  vessels  in  the  part  affected. 
It  was  the  digestive  action  of  the  gastric  juice  which 
caused  the  erosion  of  the  dead  area  and  the  formation 
of  the  characteristic  ulcer." 

The  ulcer  is  always  found  between  the  pylorus  and 
the  papilla  of  Yater,  generally  upon  the  upper  and  under 
wall  of  the  first  part.     The  ulcer  may  be  single  or  there 


«l 


Fig.   25. — Multiple    Duodenal    I'lcers   in   a   Case   of   Pedatrophy 

(Helmholz). 


may  be  two,  three,  or  four  ulcers.  The  edges  are  usually 
sharp  and  abrupt  and  have  not  the  "terraced"  appear- 
ances of  the  more  chronic  form  of  ulcer  seen  in  the 
adult.  In  these  ulcers  there  are  evidences  only  of 
destruction;  the  evidences  of  repair  are  insignificant  or 
absent.  Erosion  of  the  vessels  encountered  is  the  .cause 
of  haemorrhage,  and  complete  destruction  of  the  bowel 
wall  may  result  in  perforation. 


Melaena  Neonatorum  and  Duodenal  Ulcer     89 

SYMPTOMS  AND  DIAGNOSIS 
In  the  cases  which  prove  fatal  early — within  the  first 
seven  days  after  birth — there  are  no  earlier  signs  than 
haemorrhage.  The  infant  may  seem  normal  and  healthy 
at  birth,  but  within  a  few  hours  melaena  appears  and  con- 
tinues without  interruption.  The  child  rapidly  becomes 
pallid  and  loses  weight  speedily.     A  little  blood  may  be 


Pylorus 


Perforated  ulcer - 


Ulcer 


Fig.  26. — Perforation  of  a  Duodenal  Ulcer  in  a  Child  Two  and  a 

Half   Months  Old. 
Two  ulcers  are-  seen;   the  one  nearer  the  pylorus  has  perforated  (Dr.  Cecil 

Finny's  i  a 

vomited,  but  the  chief  discharge  takes  place  by  the 
bowel.     In  these  cases  the  onsel  of  symptoms  is  sudden, 

(heir  development  rapid,  and  the  end  is  swift.  No 
attempt  has  vet  been  made  by  operation  to  deal  with 
the  condition.  but  it  is  quite  possible  that  success  would 
attend  such  an  effort  if  made  early  and  by  experl  hands. 
In  the  latter  cases  there  would  seem  to  be  good  ground 
for  t  li«'  statements  of  1 1  elm  hoi/,  that  a  period  of  weakness, 


90  Duodenal  Ulcer 

wasting,  and  anaemia  precedes  or  accompanies  the  devel- 
opment of  an  ulcer.  His  paper  deserves  careful  atten- 
tion, and  will  probably  excite  a  keener  interest  in  this 
subject. 

In  a  later  and  fuller  paper  ("Archives  of  Pediatrics," 
1909,  September  number)  Helmholz  records  seven  cases 
in  addition  to  the  nine  which  he  had  previously  related. 
In  dealing  with  the  symptoms  he  says: 

In  only  three  of  the  seven  cases  did  the  ulcers  shew  any 
symptoms  whatsoever.  It  is  not  until  the  ulcerative  process 
has  eroded  a  vessel  or  perforated  into  the  peritoneum  that 
it  is  possible  to  diagnose  the  ulcer.  In  none  of  the  cases  did 
vomiting  call  attention  to  the  possibility  of  an  ulcer.  Even 
a  wide-spread  peritonitis  may  give  no  symptoms,  so  that 
ha'matemesis  and  melaena  remain  practically  the  only  symp- 
toms by  which  we  can  diagnose  the  ulcers,  and  when  these 
occur,  the  child  is  practically  beyond  our  aid.  In  the  majority 
of  cases  the  haemorrhages  occur,  at  the  most,  one  or  two  days 
before  the  exitus.  The  blood  in  the  stools  is  usually  intimately 
mixed  with  the  faeces,  giving  them  a  uniform,  tarry  appearance. 
If  the  haemorrhages  are  large,  the  blood  may  appear  unchanged 
in  colour  and  oftentimes  in  large  clots.  The  stools  of  the  cases 
in  which  the  ulcers  gave  no  symptoms  were  not  examined 
chemically  for  blood.  The  pathologic  histology  of  the  ulcers, 
however,  makes  it  seem  probable  that  small  vessels  are  not 
infrequently  eroded,  and  the  small  amount  of  blood  thereby 
escaping,  although  not  macroscopically  seen  in  the  stools, 
might  give  the  chemical  reaction- for  blood.  Before  it  will  be 
possible  to  give  an  adequate  idea  of  the  malignancy  of  these 
ulcers,  a  large  number  of  autopsies  of  atrophic  infants  must  be 
done,  with  special  attention  to  the  duodenum,  in  order  to 
determine  in  what  proportion  these  ulcers  are  present  without 
giving  any  symptoms.  It  seems  probable  that  these  ulcers 
are  present  in  a  much  larger  number  of  cases  than  is  at  pres- 
ent suspected,  and  that  in  comparatively  few  the  ulceration 
progresses  to  erosion  of  a  vessel  or  to  perforation. 


Melaena  Neonatorum  and  Duodenal  Ulcer     91 

TREATMENT 
The  treatment  of  melaena  neonatorum  has,  until 
recently,  been  almost  without  hope  and  entirely  with- 
out value.  When  the  haemorrhage  began  the  surgeon 
was  powerless  to  do  anything  really  effective.  As  a 
result,  however,  of  the  superb  investigations  and  accom- 
plishments of  Dr.  G.  W.  Crile  we  are  able,  in  all  cases 
of  acute  haemorrhage,  to  adopt  a  method  of  treatment 
which  is  almost  specific:  the  direct  transfusion  of  blood. 
Lespinasse  and  Fisher  in  reporting  a  case  ("Surg.  Gyn. 
&  Obst.,"    191 1,  i,  40)  say: 

The-  ideal  treatment  is  direet  transfusion  to  fill  the  baby's 
depleted  vascular  system  full  of  rich  red  blood  capable  of 
clotting  and  capable  of  carrying  oxygen,  and  this,  at  one  time, 
stops  the  haemorrhage  and  permanently  relieves  the  acute 
anaemia,  transforming  the  weak,  anaemic,  dying  child  into  a 
husky,  struggling,  rosy,  hungry  baby.  The  results  of  trans- 
fusion upon  the  newborn  are  so  marked  and  so  immediate  that 
one  can  say  it  is  just  one  degree  removed  from  the  miraculous. 

The  first  case  in  which  this  procedure  of  direct  trans- 
fusion of  blood  was  carried  out  is  recorded  by  Lambert, 
Carrel  and    Brewer    ("Med.    Rec,"    190S,    lxxiii,    885). 

riic  baby  was  born  of  healthy  parent-  and  was  delivered 
after  a  ten-hour  labour  by  an  easy  low  forceps  operation  at 
5  A.  M.  on  March  4th.  The  child  was  a  girl  and  appeared  to  be 
healthy,  weighed  8  pounds  and  12  ounces,  breathed  and  cried 
at  once,  and  shewed  no  signs  of  asphyxia.  The  blades  oi  the 
forceps  made  slight    marks  over  the  righl   zygoma  and  behind 

the  left  ear:    there  was  no  abrasion  of  the  skin.     Five  hours 
after  birth  the  cord  was  retied  because  'it  slight  oozing  from 

the    (in    end.      Twelve    hours    alter    birth    a    thickened,    dark- 


92  Duodenal  Ulcer 

coloured  spot  was  noticed  on  the  right  side  of  the  tongue,  which 
was  thought  to  be  a  naevus,  but  which  has  cleared  up  since  and 
was  undoubtedly  a  ha?matoma.  Three  hours  later  the  baby's 
temperature  was  102. 2°  F.,  and  it  was  put  to  the  breast  for 
the  first  time.  After  a  quiet  night  the  baby's  morning  tem- 
perature was  1020.  She  looked  pale  and  a  slight  amount  of 
blood  was  noticed  when  the  mouth  was  washed.  She  slept 
quietly  all  that  morning,  but  became  restless  in  the  afternoon, 
her  temperature  at  4  p.  M.  being  103. 40.  She  grew  markedly 
paler,  cried  continuously,  and  began  to  bleed  slowly  but 
steadily  from  the  nose,  and  a  hematoma  appeared  in  the 
scalp,  behind  the  left  ear.  At  9  p.  m.  this  subcutaneous  bleed- 
ing had  extended  down  the  neck  over  the  muscles,  across  the 
median  line  to  the  other  ear,  across  the  coronal  suture  over 
the  frontal  bone,  and  forward  under  the  left  ear  to  the  angle 
of  the  jaw.  The  bleeding  from  the  nose  was  continuous  and 
quite  profuse.  The  temperature  was  102. 30;  a  dark  meconium 
stool  gave  a  very  positive  reaction  for  blood,  but  the  urine  was 
of  normal  colour.  The  baby  was  of  waxen  pallor.  The  diag- 
nosis of  melsena  was  made  and  treatment  instituted  on  the 
theory  of  its  being  an  intestinal  infection.  One  dose  of  thirty 
minims  of  castor  oil  was  given,  and  two-grain  doses  of  calcium 
lactate  every  two  hours  during  the  night. 

During  March  6th  the  child  did  not  seem  to  grow  worse  so 
rapidly.  The  scalp  hematoma  increased  in  size,  and  tenseness 
and  pallor  of  the  skin  increased,  but  the  temperature  gradually 
fell  from  the  maximum  of  the  attack  at  2  p.  M.  (104.40)  until  it 
reached  97.40  at  3  p.  m.,  the  nasal  bleeding  became  less  con- 
stant, and  the  baby  nursed  regularly.  In  the  evening  of 
March  6th  and  during  March  7th  there  was  some  vomiting  of 
watery  fluid  containing  partially  digested  blood,  especially 
after  taking  the  calcium  lactate.  The  calcium  lactate  was 
stopped.  Adrenalin  was  tried  in  the  nose  at  this  time,  but 
without  effect.  The  feeding  had  to  be  done  with  a  dropper, 
for  the  baby  refused  to  nurse.  The  temperature  range  was 
97-8°  to  99.40. 

On  the  morning  of  March  8th  the  case  seemed  hopeless. 
During  this  day  the  baby's  skin  was  wraxen  white  and  the 
mucous    membrane    without    colour;    the  nasal  bleeding  was 


Melaena  Neonatorum  and  Duodenal  Ulcer     93 

continuous:  the  vomited  matter  contained  milk  curds,  dark 
blood,  and  at  times  bright  clots;  the  stools  were  frequent 
and  contained  bright-red  blood ;  the  subcutaneous  haematoma 
on  the  scalp  increased  until  the  eye  was  closed,  and  ecchymotic 
spots  appeared  on  the  legs;  the  respiration  was  rapid  and 
superficial;  the  pulse  weak — 150  to  the  minute  just  before  the 
operative  procedures. 

It  was  decided  to  attempt  a  direct  transfusion  of  blood  from 
the  father  of  the  infant  by  end  to  end  anastomosis  of  two  blood- 
vessels, after  the  manner  devised  by  Dr.  Carrel,  of  the  Rocke- 
feller Institute.  This  was  done  by  Dr.  Carrel  and  Dr.  Brewer. 
The  right  popliteal  vein  of  the  baby  was  sutured  to  the  left 
radial  artery  of  the  child's  father  without  anaesthetic  to  either 
patient,  and  enough  blood  was  allowed  to  flow  into  the  baby  to 
change  her  skin  from  a  pale  transparent  whiteness  to  a  brilliant 
red  colour.  No  measure  of  the  amount  of  blood  was  possible, 
but  the  evidences  of  a  sufficient  quantity' were  manifold.  She 
began  to  cry  lustily  and  to  struggle  against  the  bandages  which 
held  her  strapped  to  an  ironing  board.  The  wound  in  the  leg 
up  to  this  time  had  oozed  a  slight  amount  of  pale,  watery  blood 
which  did  not  clot  well.  It  began  to  bleed  freely  and  the 
blood  promptly  clotted.  The  nosebleed  stopped  instantly. 
The  pulse  became  full  and  strong  and  slowed  down,  and  the 
respirations  were  deep  and  full.  As  soon  as  the  wound  was 
sutured  and  dressed  the  baby  was  fed  an  ounce  of  milk,  which 
she  took  ravenously  and  retained  and  immediately  went  to 
sleep. 

Since  the  ending  of  the  transfusion  there  has  been  no 
haemorrhage,  no  vomiting,  and  no  diarrhoea.  Convalescence 
from  the  operation  was  uninterrupted  except  for  a  slight  in- 
fection of  the  wound.  There  was  no  evidence  of  hemolytic 
action  at  any  lime,  and  all  the  symptoms  of  melaena  ceased 
at  once.  The  next  morning  the  baby  was  found  to  be  14 
ounces  below  her  birth  weight.     She  lias  gained  steadily  since, 

and  now,  eight  weeks  after  bill  h,  she  weighs  IO  pounds  and   I  5 

ounces.  The  haematoma  was  absorbed  rapidly  except  lor  ,i 
slight  discolouration  of  the  upper  lid  of  the  right  eye,  which 
still  persists.  The  stools  became  of  normal  character  two  days 
after  the  operation.     The  wound  is  he, tied  and  the  child  ap- 


94  Duodenal  Ulcer 

pears  to  be  a  normal  child  of  its  age  today.  The  striking 
thing  in  the  case  is  that  the  disease  ceased  suddenly  and  that 
the  child  has  been  cured  from  the  moment  of  the  transfusion 
of  the  blood. 

Dr.  G.  E.  Brewer  kindly  wrote  to  me  in  September,  191 1,  to 
say  that  the  child  "promptly  recovered  from  the  operation  and 
has  had  no  sign  of  haemorrhage  since.  At  present  she  is  a 
robust,  rosy,  healthy  girl." 


Not  all  cases  of  melaena  neonatorum  are  due  to  duo- 
denal ulcer.  In  some  a  specific  taint  is  present,  and 
would  seem  to  be  an  exceedingly  serious  factor.  But 
whether  an  ulcer  be  present  or  not  is  of  no  consequence 
so  far  as  the  treatment  is  concerned.  That  should  be 
the  direct  transfusion  of  blood  at  the  earliest  possible 
moment.  The  father  is  the  most  acceptable  donor, 
and  the  quantity  he  loses  is  small.  An  eight-pound 
baby,  it  is  said,  only  has  normally  6f  ounces  of  blood. 
The  attention  of  the  operator  need  not  therefore  be 
concerned  with  the  donor,  but  care  should  be  taken  to 
see  that  the  baby  does  not  receive  the  blood  too  rapidly, 
and  suffer  thereby  an  acute  dilatation  of  the  heart. 

Lespinasse  and  Fisher  give  full  details  of  six  cases,  in 
four  of  which  there  was  complete  recovery  of  the  child. 
Their  conclusions  are: — 

1.  "Direct  transfusion  of  blood  is  the  ideal  treatment 
for  haemorrhage  of  the  newborn ;  it  meets  and  overcomes 
in  an  ideal  manner  the  three  chief  indications:  haemor- 
rhage, anaemia,  and  infection. 

2.  Transfusion  checks  the  haemorrhage  at  once. 

3.  Transfusion  cures  acute  anaemia. 

4.  Direct  transfusion  of  blood   fills  the  baby's  veins 


Melaena  Neonatorum  and  Duodenal  Ulcer     95 

with  a  plasma  that  is  more  resistant  to  infections  than 
the  original  plasma. 

5.  In  the  cases  without  syphilitic  taint  direct  trans- 
fusion of  blood  is  an  absolute  specific. 

6.  Direct  transfusion  is  best  performed  early,  but 
it  is  never  too  late,  and  the  operation  should  be  tried 
in  every  case  before  the  child  dies. 

The  following  list  gives  all  the  recorded  cases  of 
melaena  neonatorum  due  to  duodenal  ulcer. 

In  the  following  cases  death  occurred  within  one  week 
of  the  birth  of  the  infant: 

Case  i. — (Hecker  (C.),"Klinik  der  Geburtskunde,"  ii, 
1864,  244.)  Case  of  duodenal  ulcer  in  a, child  sixty-one  hours 
old.  Child  born  March  30,  1864,  died  after  sixty-one  hours, 
having  lost  if  lbs.  in  weight. 

At  the  post-mortem  the  stomach  was  found  distended  and 
contained  blackish-brown  mucous  froth  and  air.  The  mucosa 
of  the  pyloric  portion  was  stained  red,  and  from  there  to  the 
first  curve  of  the  duodenum  there  was  a  clot  of  blood  filling 
the  whole  cavity.  When  this  clot  was  removed,  an  ulcer  was 
found  on  the  anterior  part  of  the  duodenum  adjoining  the 
pancreas,  I  cm.  in  length  and  \\<l  cm.  on  its  greatest  breadth. 
On  the  base  of  the  ulcer  were  scattered  several  black  points 
which  represented  eroded  blood-vessels.  Throughout  the 
whole  intestinal  canal  there  was  found  fresh  red,  somewhat 
frothy  blood,  weighing  about  3  ounces. 

Case  2.  (Spiegelberg,  "Zwei  Falle  von  Magen-Darmblu- 
tnng  bei  Neugeborenen  in  Folge  von  Duodenal-Geschwtiren," 
"Jahrb.  f.  Kinderheilkunde,"  [869,  11.333.)  Female,  born 
November  4,  [866.  No  untoward  symptoms  on  first  three 
days.  <  )n  the  nighl  of  November  7th  suddenly  vomited  large 
quantities  of  blood  and  passed  blood  per  a  mini,  and  died  some 
hours  later  in  a  condition  of  anaemia. 

Post-mortem  made  by  Prof.  Waldeyer:  Stomach  somewhal 
distended  bj  gas,  mucosa  swollen  and  covered  with  traces  ol 


96  Duodenal  Ulcer 

blood.  At  the  commencement  of  the  duodenum  was  found 
a  circular  ulcer,  somewhat  larger  than  a  lentil  in  size,  to  which 
a  blood-clot  was  firmly  adherent.  The  ulcer  extended  deeply 
into  the  muscularis.  The  mucosa  further  down  was  very 
pale  and  covered  with  an  abundance  of  partially  fluid  and 
partially  coagulated  clot.  The  lymphatic  follicles  of  the  colon 
as  far  as  the  rectum  were  swollen  to  an  extraordinary  extent; 
otherwise  the  mucosa  of  the  intestine  was  normal. 

Case  3. — (Spiegelberg,  loc.  cit.)  Female,  born  naturally 
on  March  5,  1868.  Soon  after  birth  blood-stained  vomiting 
ensued  and  also  melaena.  Death  occurred  in  fifty-five  hours, 
shewing  symptoms  of  anaemia  similar  to  those  in  the  previous 
case. 

Post-mortem  performed  by  Prof.  Waldeyer:  Stomach  con- 
tained about  30  c.c.  of  freshly  coagulated  blood.  In  the 
duodenum,  exactly  midway  between  the  pylorus  and  the  open- 
ing of  the  ductus  choledochus,  was  a  transversely  situated 
ulcer,  1  cm.  long  and  Y2  cm-  wide,  to  the  base  of  which  a  firm 
clot  was  adherent.  Close  beneath  this  ulcer  were  two  others 
of  the  size  of  a  lentil,  the  bases  of  which  presented  clots  of 
fibrin  and  thrombosed  vessels.  The  lower  parts  of  the  intes- 
tine contained  meconium  and  coagulated  masses  of  blood. 
All  the  solitary  follicles  were  swollen  as  far  down  as  the  rectum. 

In  commenting  on  the  above  two  cases  the  author 
states  that  there  could  be  no  doubt  that  the  fatal  haemor- 
rhage had  resulted  from  the  duodenal  ulceration,  and 
the  primary  stages  of  the  process  leading  to  ulceration 
had  commenced  during  the  foetal  life. 

Case  4. — (Landau  (L.),  "Ueber  Melaena  der  Neugeborenen 
nebst  Bemerkungen  iiber  die  Obliteration  der  foetalen  Wege," 
Breslau,  1874,  p.  23.)  Female,  born  naturally  at  full  term  on 
December  25,  1873.  Had  congenital  spina  bifida.  Was 
quite  well  until  the  night  of  December  27th;  then  vomited 
chocolate-coloured  matter  and  had  profuse  bloody  diarrhoea. 
The  child  died  on  the  evening  of  December  29th  from  acute 
anaemia. 


Melaena  Neonatorum  and  Duodenal  Ulcer     97 

Post-mortem  December  30th:  The  stomach  contained 
blood-stained  masses  with  food  remains.  The  duodenum  was 
represented  by  a  distended,  sausage-shaped  body  filled  with 
blood-clot.  After  the  removal  of  the  clot  an  ulcer  was  found 
in  the  duodenum  commencing  5  mm.  from  the  pylorus  and 
extending  downwards  for  8  mm.  Its  breadth  was  6  mm. 
At  certain  points  of  the  ulcer  only  the  serous  covering  was 
left  and  the  pancreas  was  visible  through  it.  The  intestinal 
canal  contained  masses  of  blood-clot. 

Case  5. — (Lorenz  Kling,  Inaugural  Dissertation,  Miinchen, 
1875.)  Male  child,  born  May  31,  1861;  mother  a  primipara; 
normal  birth.  On  the  second  day  the  child  vomited  blood 
and  passed  bloody  motions;  continued  on  third  day ;  death  on 
the  fourth  day  after  birth. 

On  post-mortem  examination:  In  the  posterior  wall  of  the 
duodenum,  adjacent  to  the  pancreas,  was  an  ulcer  1  cm.  long 
and  \\o  cm-  broad;  only  the  mucous  membrane  destroyed. 
Further  clown,  however,  was  another  deeper  ulcer,  about  the 
size  of  a  lentil,  penetrating  to  the  serous  coat.  On  the  base 
of  the  ulcer  were  scattered  hemorrhagic  spots.  Liver  pale, 
showing  several  yellowish  islets. 

Case  6. — (Genrich,  Inaug.  Diss.,  Berlin,  1877,  Case  1,  p. 
27.)  A  healthy  child,  which  had  taken  nourishment  sixteen 
hours  after  birth,  began  suddenly,  twenty  hours  after  birth,  to 
have  haematemesis;  shortly  afterwards  melaena  occurred  and 
was  so  abundant  that  the  child  "lay  in  blood."  Death  oc- 
curred twenty-one  hours  after  birth.  At  the  autopsy  an 
ulcer  was  found  in  the  duodenum  l/2  cm.  beyond  the  pylorus; 
it  extended  over  three-fourths  of  the  circumference  of  the 
bowel  and  was  2  cm.  in  breadth. 

Case  7.  -(Kundrat,  Gerhardt,  "Handbuch  d.  Kinder- 
krankheiten,"  [880,  lv,  2,  p.  398.)  Female,  seven  days  old, 
died  April  13.  1877,  from  melaena.  Had  been  a  well-developed 
child  and  otherwise  healthy. 

On  post-mortem  examination:  In  the  anterior  wall  of  the 
duodenum,  2  mm.  below  the  pylorus,  was  an  ulcer  4  mm.  long 
and  2  mm.  broad.  On  the  posterior  wall  1  cm.  below  the 
pylorus  was  another,  5  mm.  long,  3  mm.  broad,  transversely 
placed.  Both  ulcers  were  covered  with  adhering  clots.  <  >n 
7 


98  Duodenal  Ulcer 

removing  the  clot  covering  the  second  ulcer  a  bleeding  vessel 
was  exposed.  The  bleeding  vessel  proved  to  be  a  branch  of 
the  gastro-duodenal  artery. 

Case  8.— (P.  v.  Zerschwitz,  "Munch,  med.  Woch.,"  1888, 
xxxv,  483.)  K.  M.,  male,  born  January  II,  1888,  of  a  II- 
para.  On  the  evening  of  the  second  day  napkins  were  found 
blood-stained.  Child  passed  at  first  dark  and  then  red  blood 
per  anum.  Continued  until  death  occurred  on  the  13th 
(third  day  after  birth). 

On  post-mortem  examination  the  alimentary  canal  con- 
tained a  large  amount  of  blood.  In  the  duodenum  were 
several  firm  blood-clots.  In  the  posterior  wall,  about  1  cm. 
above  the  opening  of  the  ductus  choledochus,  was  an  oval 
ulcer,  the  length  of  which  was  13  mm.  and  breadth  7.5  mm. 
The  ulcer  had  a  terraced  appearance.  The  gastro-duodenal 
artery  was  empty  and  a  sound  passed  into  it  came  out  at  the 
base  of  the  ulcer. 

Case  9. — (Miinchmeyer,  "Centralblatt  f.  Gynak.,"  1889, 
xiii,  286.)  Child  two  days  old,  born  partly  asphyxiated  after 
a  prolonged  labour.  Melaena  set  in  two  days  after  birth  and 
death  occurred  in  a  few  hours. 

On  post-mortem  examination  two  small  superficial  ulcers 
with  irregular  margins  were  found  on  the  duodenum  close  to 
the  pylorus. 

Case  10. — (T.  D.  Lister,  "Trans.  Path.  Soc.  Lond.,"  1899, 
i,  ill.)  This  specimen  shews  a  shallow  ulcer  in  the  duodenum, 
about  \i  inch  from  the  pylorus.  Its  edge  is  slightly  raised 
and  shelves  gradually  to  the  centre  of  the  ulcer  and  into 
the  surrounding  duodenal  wall.  At  the  centre  the  ulcer 
deepens  suddenly  into  the  submucous  tissue,  and  its  base 
is  semi-transparent  for  an  area  of  about  2  mm.  by  1  mm. 
In  the  recent  condition  the  ulcer  was  covered  by  an  adherent 
clot,  which  apparently  extended  on  to  a  rather  large  vessel  at 
the  base  of  the  ulcer,  and  which  seemed  to  be  derived  from  the 
gastro-duodenal  artery.  The  intestines  were  full  of  blood- 
clot,  but  there  was  nothing  abnormal  in  their  walls. 

Abstract  of  case:  Baby  C,  aged  three  days,  was  admitted 
to  the  East  London  Hospital  for  Children  under  Dr.  Donkin 
on  November  29,  1 897.     The  patient  was  passing  blood  per 


Melaena  Neonatorum  and  Duodenal  Ulcer     99 

rectum.  A  saline  enema  was  administered,  and  this  was 
followed  by  a  profuse  haemorrhage,  leaving  the  patient  very 
anaemic  and  collapsed.  Death  occurred  November  30th,  the 
patient  being  then  four  days  old. 

Case  ii. — (de  Xoble  (Paul),  "  Presse  med.  Beige,"  1892, 
xviv,  p.  409;  abstr.  in  "Schmidt's  Jahrbticher,"  1893,  ccxxxviii. 
p.  167.)  Author  delivered  child  with  forceps;  it  vomited 
blood  twenty-four  hours  after  birth,  and  evacuated  blood  with 
-tools.  This  act  was  repeated  three  times  within  twenty-four 
hours  and  caused  the  child's  death. 

The  autopsy  shewed  that  it  had  lost  900  gr.  in  weight.  The 
umbilical  cord  was  intact;  the  vena  cava  inferior  was  con- 
gested and  filled  with  blood.  The  whole  intestine  was  filled 
with  masses  of  coagula.  In  the  upper  portion  of  the  duode- 
num there  was  a  superficial  ulcer  with  irregular  edges.  The 
mucosa  of  the  stomach  and  caecum  was  injected.  In  the 
kidneys  there  were  numerous  uric  acid  infarcts. 

CASE  12. — (Rheiner  (G.),  "Corr.-Bl.  fur  Schweizer  Aerzte," 
1898,  xxviii,  p.  524;  abstr.  in  "Schmidt's  Jahrbiicher,"  1901, 
cclxx,  p.  260.)  Child  born  of  healthy  parents,  not  asphyctic 
at  birth;  six  hours  after  delivery  had  blood-stained  stool. 
The  haemorrhages  were  repeated.  Death  occurred  on  the 
fifth  day. 

Post-mortem:  Upon  section  an  ulcer  was  found  in  the 
duodenum. 

Case  13. — Saxer  ("  Medizinische  Gesellschaft  zu  Leipzig," 
"Miinchen.  med.  Woch.,"  1902,  xlix,   1362)  demonstrated  a 

e  of  fatal  intestinal  haemorrhage  from  a  small  ulcer  of  the 
duodenum  close  beneath  the  pyloric  ring  in  an  infant  three 
days  old. 

CASE  14-  (Kendall  (H.  \\\),  "Duodenal  Ulcer  in  a  Child 
Forty-four  Hours  Old,"  "Brit.  Jour.  Child.  Dis.,"  [906,  iii, 
501.)  The  child  was  born  quite  healthy  and  of  good  weight. 
Twenty-seven   hours  after   birth    it    vomited   a   quantity  of 

blood,    and    at     the    -ami-    linn-    passed    blood    per    anum.      It 

passed  a  lit  tie  more  blood  a  leu  hour-  afterward-  and  was  very 
weak.  Thirty-six  hours  after  the  lir-t  vomiting  ii  passed 
more  blood,  and  died  later  from   haemorrhage.      The  mother 


ioo  Duodenal  Ulcer* 

was  very  healthy.  The  father's  state  of  health  was  unknown. 
The  child  was  illegitimate. 

Case  15. — (L.  Kuttner,  "Berlin,  klin.  Woch.,"  Nov.  9, 
[908.)  Infant,  seven  days  old,  developed  vomiting  and 
diarrhoea.  Blood  was  observed  in  the  stools  when  child  was 
nine  days  old.  On  admission  to  hospital  diarrhoea  continued. 
When  child  was  thirty  days  old  a  sudden  profuse  haemorrhage 
from  the  bowel  occurred.  The  blood  was  bright  red  in  colour 
and  suggested  that  the  bleeding  came  from  the  lower  bowel. 
Digital  examination  per  rectum  wyas  negative.  The  child 
rapidly  sank  as  a  result  of  the  bleeding  and  death  occurred 
three  hours  later. 

At  the  post-mortem  the  duodenum  shewred  in  the  first  part 
a  circular  ulcer  5  mm.  in  diameter.  The  edges  of  this  ulcer 
were  dark  in  colour  and  the  base  was  undermined.  The 
Peyer's  patches  and  lymph-follicles  were  smaller.  The  in- 
testines contained  blood-stained  faeces  and  dark,  fluid  blood. 

Case  16. — (Henoch,  "Vorlesungen  iiber  Kinderkrankhei- 
ten,"  nth  ed.,  1903,  pp.  59  et  seq.)  Two  ulcers  were  found 
in  the  body  of  an  infant  who  had  died  of  melaena.  No  other 
details  are  given. 

In  the  following  cases  death  occurred  over  one  week 
after  the  birth  of  the  infant: 

Case  17. — (V.  Torday,  "Jahrb.  fur  Kinderheilk.,"  1906, 
Ixiii,  563,  and  abstract  in  "Cent.  f.  Verdauungs-Krank.," 
1907,  ii,  191 .)  C.  T.,  eight  months  old,  admitted  to  the  Buda- 
pest children's  asylum  March  4,  1905,  writh  rickets  and  wasting. 
Constipation  and  vomiting,  but  no  trace  of  blood  in  vomit  or 
-tools.  Gradual  wasting;  death  April  18th  with  pulmonary 
symptoms. 

Post-mortem:  Stomach  very  much  contracted;  tip  of  little 
finger  with  difficulty  admitted  through  the  pyloric  open- 
ing. Five  mm.  below  the  pylorus,  along  the  lesser  curvature, 
was  a  round  ulcer,  8  mm.  long,  extending  over  both  anterior 
and  posterior  walls.  Margins  of  the  ulcer  were  soft,  smooth, 
and   white.      In    the   centre   was   a   small   hemorrhagic   spot 


Melaena  Neonatorum  and  Duodenal  Ulcer   101 

shewing  an  erosion  of  a  vessel.  The  contents  of  the  small 
intestine  were  brownish-red  in  colour  and  in  part  tarry. 
Bronchopneumonia  was  present  in  the  right  upper  lobe. 

Case  18. — (Borland  (H.  H.),  "Lancet,"  1903,  ii,  1084.) 
Infantile  acute  eczema;  haematemesis ;  duodenal  ulcer;  death: 
This  unique  condition  of  duodenal  ulcer  following  acute 
eczema  occurred  in  an  infant  of  eight  months.  Eczema  capitis 
began  when  the  infant  was  two  months  old  and  persisted  in 
moderate  severity  until  about  a  week  before  death.  Then 
there  was  an  exacerbation  of  the  eczema,  which  was  intense, 
affecting  the  head,  neck,  and  part  of  the  trunk.  There  was 
much  oedema  of  the  face  and  a  great  number  of  vesicles  and 
pustules  formed.  On  the  fourth  day  after  the  exacerbation 
began  the  infant  vomited  blood,  and  from  this  time  on  the 
stools  were  tarry.  During  the  next  two  days  there  was  severe 
retching  and  some  vomiting  of  blood,  together  with  evidences 
of  acute  abdominal  pain,  and  the  baby  died  after  vomiting  a 
single  mouthful  of  bright  red  blood. 

The  necropsy  revealed  a  few  ounces  of  bloody  serum  in 
the  peritoneum,  but  no  evidence  of  peritonitis.  The  lesser 
sac  of  the  peritoneum  contained  a  clot  filling  practically  the 
entire  space.  On  the  posterior  wall  of  the  duodenum,  just 
below  the  pylorus,  was  found  a  round  ulcer  with  punched-out 
edges;  the  perforation  was  about  the  size  of  a  split-pea  and 
directed  towards  the  lesser  sac.  The  stomach  contained 
altered  blood  and  its  mucous  membrane  was  merely  congesn  id. 

In  commenting  upon  the  case  the  author  calls  atten- 
tion to  the  analogous  occurrence  of  such  duodenal  ul- 
1  ers  in  cases  o!  burns  on  the  skin,  particularly  in  young 
subjects. 

Case  i<>.  (Kuttner,  "Berlin,  klin.  Woch.,"  Nov.  9,  [908.) 
Child,  aged  tour,  quite  well  all  it-  life.  On  the  day  before 
admission  began  to  have  diarrhoea,  which  continued  during 
it>  stay  in  tin-  hospital.  Six  days  after  admission  a  profuse 
attack  of  hamatemesis  occurred,  and  the  child  died  shortly 
afterwards. 


102  Duodenal  Ulcer 

Post-mortem  examination:  The  abdominal  cavity  con- 
tained about  100  c.c.  of  turbid  yellow  fluid.  In  the  duodenum 
just  below  the  pylorus  were  three  ulcers  varying  in  size  from 
a  pea  to  a  penny  piece.  These  ulcers  involved  all  the  coats  of 
the  intestine  except  the  peritoneal  coat.  The  mucous  mem- 
brane of  the  large  intestine  was  red  and  swollen  and  shewed 
sloughing  areas.     The  cortex  of  the  kidneys  was  swollen. 

Pathological  report:  Pseudo-membranous  eolitis.  Duo- 
denal ulcers.     Parenchymatous  nephritis. 

Cask  20. — (Adriance  (Vanderpoel),  "Archives  of  Pedi- 
atrics," 1 901,  xviii,  277.)  Duodenal  ulcer  in  an  infant  of  ten 
months;  chronic  ulcerative  follicular  colitis:  E.  R.,  male, 
born  December  6,  1899.  Admitted  to  the  Nursery  and 
Child's  Hospital  on  August  23,  1900,  with  vomiting  and  dis- 
tended abdomen.  In  spite  of  careful  dieting  the  child  became 
worse,  and  before  death  there  was  almost  constant  vomiting. 
Blood  was  vomited  three  times  and  a  considerable  amount  of 
blood  was  passed  in  the  stools.  Death  occurred  October  6, 
1900,  the  child  being  then  ten  months  old. 

On  post-mortem  examination  the  stomach  was  found  to 
contain  bright,  not  partially  digested  blood.  In  the  posterior 
wall  of  the  duodenum  just  below  the  pylorus  was  a  small  oval 
ulcer  measuring  I  by  2  cm.  The  margins  of  the  ulcer  were 
sharply  cut  out,  shewing  no  induration.  Its  base  was  formed 
by  the  head  of  the  pancreas,  to  which  it  was  firmly  adherent. 
The  remaining  portion  of  the  small  intestine  wras  normal. 
The  large  intestine  shewed  numerous  ulcerated  solitary 
follicles.  The  liver  was  fatty.  The  mesenteric  lymph-glands 
were  moderately  enlarged. 

Case  21. — (Finny,  "  Proceedings  of  the  Royal  Soc.  of  Med.," 
Dec,  1908.)  Male  child,  born  April  12,  1908,  of  a  primipara; 
healthy  at  birth,  but  began  to  vomit  a  few  days  afterwards, 
which  continued  until  death,  on  June  27th,  when  ten  weeks 
old.  There  was  visible  peristalsis  in  the  stomach.  The  stools 
were  at  times  dark  and  tarry.  Death  occurred  suddenly 
from  an  internal  perforation. 

On  post-mortem  examination  the  stomach  was  found  much 
distended.  The  duodenum  was  found  inflamed  and  thickened 
2  inches  from  the  pylorus.     On  its  posterior  aspect,  near  the 


Melaena  Neonatorum  and  Duodenal  Ulcer  103 

liver,  was  a  perforation  from  which  bile-stained  material  was 
oozing.  The  pyloric  opening  was  very  narrow,  just  admitting 
a  silver  director.  On  opening  the  duodenum  two  ulcers  were 
found  on  its  posterior  wall.  Both  had  a  punched-out  appear- 
ance. The  floor  of  one  had  given  way,  but  that  of  the  other, 
though  very  thin,  still  remained.  There  were  no  other  ulcers 
anywhere  and  all  the  other  organs  were  healthy. 

Case  22. — (Veit,  "Zeitschrift  f.  klin.  Med.,"  1881,  iv,  471. 
and  "Deut.  med.  Woch.,"  1881,  vii,  681.)  Case  of  melaena 
neonatorum  associated  with  a  duodenal  ulcer:  Child  seven 
weeks  old,  well  developed,  died  in  convulsions.  No  actual 
melaena,  but  motions  were  greenish-yellow;  blood-stained 
froth  and  coffee-ground  material  came  from  mouth. 

On  post-mortem  examination  stomach  and  intestines 
appeared  dark  brown.  In  the  interior  of  the  duodenum  was 
a  large  clot.  When  this  was  removed,  two  ulcers  were  seen  in 
the  upper  horizontal  portion.  They  penetrated  as  far  as  the 
serosa,  but  did  not  perforate  it.  The  mesenteric  glands  were 
swollen.  The  intestines  contained  a  large  quantity  of  blood 
and  clots. 

The  following  cases  are  recorded  by  Helmholz  in  his 
paper  ("Deut.  med.  Woch.,"  1909,  i,  534): 

Case  23. — Child,  two  months,  admitted  July  3d;  wasting 
and  diarrhoea;  stools  thin  and  watery;  no  history  of  lues; 
collapse.     Death,  August  19th. 

Post-mortem,  five  hours  after  death:  riidit  ventricle  di- 
lated; hyperemia  of  lungs ;  spleen  enlarged ;  stomach  covered 
with  thick  mucus.  In  the  duodenum,  about  '  •?  cm.  above  the 
papilla  of  Vater,  were  two  large  ulcers,  1  riradiate,  punched-out, 
and  having  smooth  bases;  immediately  below  the  pylorus  was 
another  small,  sharply  defined  ulcer,  2  mm.  in  diameter. 

Microscopic  examination  of  ulcer:  Section  through  the 
middle  of  the  ulcer  -hewed  degeneration  of  the  mucous  coat, 
hyaline  necrosis  ol  the  superficial  coats,  increase  ol  connective 
tissue,  small-celled  infiltration  of  the  muscularis. 

Case  24.     Hildegard  0.,  six  weeks  old,  born  July  4,  [908; 


104  Duodenal  Ulcer 

admitted  July  13th;  died  August  20,  1908.  On  admission, 
child  pale;  intertrigo,  aphtha?,  and  vulvitis  present.  Dyspep- 
sia— fed  on  buttermilk.  Rapid  emaciation;  stools  green  and 
slimy.     Temperature  subnormal.     Death  from  collapse. 

Post-mortem:  Duodenum  shewed  small  haemorrhages  in 
the  mucosa.  On  a  line  with  the  papilla  of  Vater  was  a  small 
ulcer,  about  2  mm.  in  diameter,  filled  with  yellowish-brown 
matter.  No  haemorrhage  to  be  seen  on  margins  of  the  ulcer. 
Contents  of  the  upper  part  of  the  small  intestine  were  blood- 
stained. Peyer's  patches  and  the  solitary  follicles  were  swol- 
len. No  ulceration.  Lungs  shewed  hypostatic  congestion. 
Heart  normal.     Stomach  contained  much  mucus. 

Case  25. — Martin  H.,  six  weeks  old,  born  July  8,  1908; 
admitted  July  27th;  died  August  21,  1908.  History  of  maternal 
syphilis.  On  admission,  snuffles  and  depressed  nose.  Dys- 
pepsia relieved  at  first  by  buttermilk.  On  August  14th 
stools  became  thin  and  slimy.  Rapid  emaciation  in  spite  of 
all  measures.  Obstinate  constipation,  then  passage  of  black, 
tarry  stools.     Died  suddenly  in  collapse. 

Post-mortem:  Duodenum  contained  blood-stained  masses; 
whole  of  the  mucosa  reddened.  About  I  cm.  below  the 
pylorus  was  a  sharply  circumscribed,  punched-out  ulcer  about 
3  by  4  mm.  in  size.  The  base  of  the  ulcer  was  flat  and  greyish- 
yellow  in  colour,  shewing  several  haemorrhagic  spots.  Margins 
partly  overhanging  and  partly  flattened.  Serosa  intact. 
Immediately  below  this  ulcer  was  a  second  one,  more  super- 
ficial, 2  mm.  in  diameter.  Base  greyish-red,  also  shewing  a 
few  small  haemorrhages.     Heart  and  lungs  normal. 

Case  26. — Willie  R.,  six  weeks  old,  born  July  16,  1908; 
admitted  July  30th;  died  August  26,  1908.  On  admission, 
well-nourished  child.  Dyspepsia.  Rapid  emaciation;  tem- 
porary improvement  with  centrifugalised  breast-milk.  Stools 
became  offensive.     Died  suddenly  in  collapse. 

Post-mortem:  Suppurative  peritonitis  commencing  around 
pylorus,  localised  to  right  hypochondrium.  A  small  perfora- 
tion was  present  in  the  duodenum  just  below  the  pylorus, 
and  this  was  the  cause  of  the  peritonitis.  On  opening  the 
stomach  and  duodenum  an  ulcer  was  seen  in  the  latter  im- 
mediately below  the  pylorus,  about  3  mm.  in  diameter.     The 


Melaena  Neonatorum  and  Duodenal  Ulcer   105 

ulcer  was  punched-out,  but  the  terraced  appearance  was  not 
evident.  There  were  two  very  small  ulcers  close  by,  and 
another  about  1 3^2  cm-  lower  down.  All  these  three  presented 
a  similar  punched-out  appearance.  The  stomach  and  in- 
testines contained  blood-stained  masses.  Hypostatic  con- 
gestion of  lungs.     Spleen  soft.     Other  organs  normal. 

Case  27. — Kurt  K.,  seven  weeks  old,  born  July  8,  1908; 
admitted  July  20th;  died  August  29,  1908.  On  admission, 
emaciation,  offensive  stools.  One  blood-stained  motion 
shortly  before  death. 

Post-mortem:  Perforating  ulcer  of  duodenum  just  below 
the  pylorus;  fibrinous  adhesions  around  the  perforation  pre- 
venting peritonitis.  On  opening  the  stomach  and  duodenum  a 
large  ulcer  was  seen,  5  by  1  cm.  in  size.  The  perforation  was 
2  mm.  in  diameter  and  situated  at  the  upper  end  of  the  ulcer. 
The  duodenal  wall  appeared  almost  wholly  destroyed,  and  at 
the  base  of  the  ulcer  a  large,  eroded  artery  was  seen.  There 
was  a  large  quantity  of  blood  in  the  upper  part  of  the  small 
intestine. 

Case  28. — Alfred  K.,  fourteen  weeks  old,  born  May  27, 
1908;  admitted  June  2nd;  died  September  2,  1908.  On  admis- 
sion, a  well-nourished  child.  Dyspepsia;  wasting;  offensive 
stools;    died  suddenly. 

Post-mortem:  Midway  between  pylorus  and  papilla  of 
Vater  were  two  small,  punched-out  ulcers,  2  to  3  mm.  in  diam- 
eter. Edges  uneven  and  partly  overhanging,  base  greyish 
in  colour.  Numerous  haemorrhagic  foci  seen  on  the  margins. 
Intestine  otherwise-  normal.  Thymus  atrophied.  Other  or- 
gans normal. 

Case  29. — Erich  S.,  four  months  old,  admitted  September 
1,  1908;  died  September  25,  1908.  On  admission,  poorlj 
nourished  child;  diffuse  bronchitis.  Black,  tarry  motions 
continued  for  two  days.  Child  became  very  anaemic 
527.000  reds  per  cubic  millimetre.  Haemoglobin  15  per  cent. 
Saline  infusions  and  gelatin  subcutaneously.  Heath  from 
anaemia. 

Post-mortem:  In  the  duodenum,  4  nun.  below  the  pylorus, 
was  an  ulcer  6  by  [.8  cm.  in  measurement.  Base  ol  the  ulcer 
was  thickly  covered  with  mucus.     On  removal  of  this  it  was 


106  Duodenal  Ulcer 

seen  that  the  upper  part  of  the  ulcer  was  deeper  than  the  lower. 
Another  ulcer  present,  Y2  cm.  below  the  pylorus,  2  mm.  in 
diameter.  The  solitary  follicles  were  enlarged;  otherwise 
intestine  normal.  After  suitable  preparation  the  specimen 
shewed  the  terraced  appearance  of  a  typical  peptic  ulcer. 

Case  30. — William  T.,  ten  weeks  old,  born  August  10,  1908; 
admitted  September  28,  1908;  died  October  28,  1908.  On 
admission,  slight  jaundice,  dyspepsia,  offensive  stools,  wasting. 
Death  from  pulmonary  complications. 

Post-mortem:  In  the  duodenum,  ^  cm.  below  the  pylorus, 
was  an  oval,  punched-out  ulcer,  measuring  2  by  4  mm.  The 
margins  were  smooth  and  the  base  wras  clean.  Midway  be- 
tween the  pylorus  and  the  papilla  were  two  ulcers,  one  very 
superficial,  about  2  mm.  in  diameter;  the  second  was  deeper, 
more  irregular,  about  the  same  size  as  the  one  near  the  pylorus. 
The  upper  portion  of  the  intestine  contained  much  blood. 
The  lungs  shewed  pneumonic  consolidation  posteriorly  more 
marked  on  the  right  side.     Other  organs  normal. 

Reference  to  other  cases  as  yet  unpublished  will  be 
found  in  Helmholz's  article  ("Archives  of  Pediatrics," 
Sept.,   1909). 


CHAPTER  VI 

CHRONIC  DUODENAL  ULCER-SYMPTOMS  AND 
DIAGNOSIS 

There  are  few  diseases  whose  symptoms  appear  in 
such  a  definite  and  well-ordered  sequence  as  is  observed 
in  duodenal  ulcer.  It  is  true  that  there  are  cases,  of 
which  fuller  details  must  presently  be  given,  in  which 
the  regular  appearance  of  the  symptoms  is  absent,  or 
in  which  one  symptom  is  so  exaggerated  as  to  dwarf,  or 
even  to  destroy,  the  value  of  others.  But  these  excep- 
tions are  few,  and  they  do  not  belittle  the  value  of  the 
general  statement  that  the  symptoms  of  duodenal  ulcer 
are  definite,  and  not  easily  to  be  mistaken,  and  that 
they  appear  in  an  order  and  with  a  precision  which  are 
indeed  remarkable. 

The  patient  may  date  his  complaint  from  an  early 
period  in  his  life.  It  is  not  very  uncommon  for  a  man, 
in  answer  to  the  question  as  to  how  long  he  has  suffered. 
to  reply,  "All  my  life."  A  man  of  sixty-one,  upon 
whom  I  operated,  had  first  experienced  symptoms  at 
the  age  of  nineteen;  others  had  symptoms  "as  long  as 
they  could  remember."  This  goes  to  shew  that  the 
ulceration  or  i t -  antecedent  may  begin  .it  an  early  period 
in  life,  and  the  symptoms  may,  with  periods  ol  repose, 
continue  up  to  middle  age,  or  even  to  advanced  years. 
\-   ,i    rule    the   patient    i-.   in   middle  age      from    twenty- 


io8  Duodenal  Ulcer 

five  to  forty-five;  and  males  are  more  frequently  affected 
than  females.  If  the  earlier  history  is  well  remembered, 
the  patient  will  say  that  insidiously,  almost  impercepti- 
bly, be  began  to  suffer  from  a  sense  of  weight,  oppression, 
or  distension  in  the  epigastrium  after  meals.  At  the 
first  the  discomfort  may  apparently  be  capricious,  but 
it  is  not  long  before  notice  is  taken  of  the  fact  that  it 
comes  usually  two  hours  or  a  little  more  after  food  has 
been  taken.  Immediately  after  a  meal  there  is  ease; 
if  pain  or  discomfort  were  present  before,  the  meal 
relieves  them,  and  soon  banishes  them  completely  for  a 
time.  Then  again  the  pain  is  felt  in  two  hours,  three 
hours,  four  hours,  or  sometimes  even  six  hours  later. 
When  the  pain  comes  three  or  four  hours  after  food, 
I  have  found  that  the  ulcer  is  "tucked  back";  it  is, 
that  is  to  say,  adherent  posteriorly  in  such  manner  as  to 
prevent  its  delivery  into  the  abdominal  wound.  One 
feels  that  if  much  traction  is  made  on  the  duodenum,  the 
ulcer  would  be  pulled  away  from  the  upper  part  of  the 
kidney  pouch.  The  position  of  the  pre-pyloric  vein 
shews  that  the  ulcer  is  in  the  first,  and  not,  as  might  be 
supposed,  in  the  second,  part  of  the  bowel.  When  the 
pain  consistently  comes  at  an  earlier  time  than  two  hours 
after  food,  two  conditions  may  be  found:  either  an 
active  ulcer  has  contracted  recent  adhesions  to  the 
abdominal  wall  or  the  liver;  or  stenosis  is  beginning 
to  develop.  In  some  cases  the  pain  may  come  more 
quickly  because  the  food  is  restricted  entirely  to  fluids. 
Patients  may  go  for  months  or  even  for  years  without 
taking  a  meal  of  solid  food.  With  an  exclusively  liquid 
diet  the  pain  comes  generally  in  an  hour,  less  or  more, 


Chronic  Duodenal  Ulcer  109 

after  the  meal.  As  a  rule,  the  pain  comes  gradually. 
and  gradually  increases,  becoming  more  severe  and 
being  accompanied  by  a  sense  of  fullness,  distention, 
a  ''blown-out"  feeling,  and  there  is  an  eructation  of 
bitter  fluid  or  of  gas,  which  affords  relief.  The  interval 
between  the  taking  of  food  and  the  onset  of  the  pain 
is  very  remarkable;  it  is  constant  from  day  to  day  if 
the  character  and  quantity  of  the  food  remain  the  same. 
If  the  food  is  entirely  liquid,  the  pain  comes  rather 
earlier;  if  it  is  heavy,  solid,  "indigestible,"  the  pain 
comes  later;  with  an  ordinary  meal,  of  liquid  and  solid, 
the  pain  very  rarely  appears  in  less  than  two  hours. 
Many  patients  will  volunteer  the  statement  that  the 
pain  begins  to  appear  "when  they  are  beginning  to  feel 
hungry,"  and  I  therefore  suggested  in  one  of  my  early 
papers  the  term  "hunger  pain"  as  descriptive  of  this 
particular  symptom.  The  pain,  as  a  rule,  is  noticed, 
at  first,  only  or  chiefly  after  the  heaviest  meal  of  the  day. 
If  dinner  is  taken  between  1  p.  M.  and  2  p.  m.,  the  pain 
will  come  with  unvarying  regularity  at,  or  near,  4  p.  M. 
For  a  long  period  this  may  be  the  only  time  of  day 
when  discomfort  is  felt,  but  later  in  the  attack,  or  in 
subsequent  attacks,  it  is  noticed  that  after  every  meal 
the  pain  comes  at  its  characteristic  interval,  and  that  by 
every  meal  the  pain  is  relieved,  only  to  return  in  due 
time.  When  inquiry  is  made  from  a  patient  as  to 
whether  food  causes  the  pain,  he  will  not  seldom  answer, 
"Oh,  no;  food  always  make-,  the  pain  better;  the  pain 
conic-  when  I  am  beginning  to  feel  hungry."  It  is  a 
very  characteristic  feature  of  the  pain  thai  it  wake-  the 
patient  in  the  night,  and  constant!}   the  time  of  waking 


no  Duodenal  Ulcer 

is  said  to  be  2  o'clock.  The  relief  of  the  pain  by  food, 
quickly  realised  by  patients  themselves,  leads  to  the 
practice  of  keeping  near  at  hand  a  biscuit  or  some  other 
food  or  drink  which  can  be  taken  at  once.  Many 
patients  carry  a  biscuit  in  the  pocket,  or  have  a  glass  of 
milk  and  a  piece  of  bread  and  butter  ready  at  certain 
times,  to  be  taken  at  the  moment  of  the  onset  of  pain. 
It  is  a  common  experience  to  find  that  patients  place 
by  their  bedsides  some  food  to  be  taken  in  the  early 
hours  of  the  morning  when  the  pain  awakens  them. 
The  regular  appearance  of  the  pain  after  definite  inter- 
vals from  the  taking  of  food  is  remarkable,  and  is  con- 
sistent. The  pain  is  often  preceded  or  accompanied  by 
a  sensation  of  weight  or  of  fullness  and  distension  in  the 
epigastrium;  it  is  described  as  "boring,"  "gnawing," 
"burning."  It  may  be  relieved  by  belching,  and  con- 
stant efforts  are  often  made  to  bring  about  the  eructa- 
tion of  gas,  which  is  followed  by  momentary  relief. 
Sometimes  there  may  be  a  slight  regurgitation  of  food, 
and  the  patient  complains  that  the  taste  of  this  is  bitter 
or  acid;  the  throat  then  feels  hot  or  as  if  scalded,  and 
the  teeth  are  said  to  feel  as  if  made  of  chalk.  A  few 
patients  complain  that  a  free  gush  of  saliva  may  occur. 
The  swallowing  of  this  may  give  temporary  relief  to 
the  pain.  In  some  cases  the  flow  of  saliva  may  be 
copious  and  distressing.  For  long  periods,  sometimes 
throughout  the  history  of  the  case,  the  pain  remains 
confined  to  the  epigastrium,  but  it  may  strike  through 
to  the  back  or  pass  round  the  right  side.  When  the 
pain  is  severe,  relief  is  often  gained  by  pressure,  and  I 
have   known   patients  wakened   in   the  night   to  hug  a 


Chronic  Duodenal  Ulcer  1 1 1 

pillow  to  the  abdomen  to  obtain  relief  in  this  way.  On 
some  occasions,  though  this  is  infrequent,  the  pain  is 
said  to  be  "cramp-like"  in  character;  a  sort  of  spasm 
is  felt,  with  exacerbations  and  remissions,  as  in  all  forms 
of  "colic."  It  is  very  probable  that  a  spasm  of  the 
pylorus,  protective,  no  doubt,  in  its  character,  is  actually 
present;  for  such  a  condition,  as  I  pointed  out  several 
years  ago,  may  be  witnessed  during  the  conduct  of  an 
operation.  The  pyloric  muscle  hardens  by  degrees  until 
a  state  of  firm  contraction  is  reached,  when  a  solid, 
cylindrical,  whitish  mass  forms,  which  imparts  a  feeling 
similar  to  that  experienced  when  the  normal  uterus  is 
handled.  The  spasm  slowly  passes  away  and  the 
stomach  assumes  its  normal  appearance.  This  sen- 
sation of  cramp  is  often  accompanied  by  a  feeling  of 
great  epigastric  distension.  I  have  twice  seen.this  cramp 
well  marked  in  patients  who  were  operated  upon  under 
local  anaesthesia  only:  they  both  described  their  sen- 
sations at  the  moment  as  one  of  "bursting"  and  "dis- 
tension."* Throughout  the  whole  period  during  which 
the  pain  is  felt  the  appetite  remains  good.  In  main 
cases  the  patient  volunteers  the  statement  that  he  feels 
a  keen  relish  for  his  food,  takes  it  with  good  appetite, 
and  enjoys  it.  Frequently  he  eats  less  than  he  feels  he 
could  enjoy,  because  experience  has  taught  him  that 
excess,  or  even  satisfaction,  is  apt  to  be  followed  by  an 
increase  of  pain,  or  pain  of  a  more  enduring  character. 

*  I  have  often  wondered,  since  t Hi—,  whether  the  "colic"  described  l>\ 
patient  -  [hepatic  colic,  renal  colic,  intestinal  colic)  is  due,  as  we  have  always 
supposed,  to  ili"  contraction  of  unstriped  muscular  tissue;  it  i-  possible 
thai  it  i-  rather  the  resull  <il  the  distension  which  i>  presenl  behind  the 
3egmen1  in  which  t lie  muscular  spasm  is  occurring. 


I  12 


Duodenal  Ulcer 


Fluid  food,  when  taken  to  the  exclusion  of  all  solids, 
often  causes  the  pain  to  come  earlier  after  food  and  to 
last  longer  than  when  the  ordinary  meals  are  taken. 
A  patient  will  often  say  that  he  feels  worse  when  he  is 
strictly  dieted  in  this  way;  but,  as  a  rule,  persistence  in 
liquid  diet,  especially  during  the  earliest  stages  of  the 
disease,  will  bring  relief  after  a  time.  Vomiting  is  very 
infrequent;  it  is  rarely  present  until  stenosis  develops, 
and  stenosis  appears  only  in  the  later  periods  when  the 
ulcer  or  ulcers  are  healed.  A  severe  pyloric  cramp, 
which  may  be  caused  by  an  active  ulcer,  produces,  of 
course,  an  evanescent  stenosis.  The  majority  of  the 
patients  upon  whom  I  have  operated  have  never  vomited. 
These  are  the  characteristic  symptoms  described  by 
the  patient  in  the  anamnesis.  Upon  them  alone  a  con- 
fident diagnosis  of  duodenal  ulcer  may  be  made.  Cer- 
tainly the  most  characteristic  feature  enabling  a  diag- 
nosis of  chronic  duodenal  ulcer  to  be  made  is  the  perio- 
dicity of  the  symptoms  and  their  recurrence  from  time 
to  time  in  "attacks,"  their  complete  abeyance  in  the 
intervals.  A  single  probably  brief  attack  of  these 
symptoms  may  mean  that  a  superficial  lesion  is  present 
in  the  duodenum;  but  as  to  this  I  cannot  say,  as  I  have 
only  once  operated  after  a  first  attack.  In  this  case 
I  excised  a  little  white  patch  from  the  duodenum,  but 
did  not  at  the  time  feel  at  all  sure  that  it  was  an  ulcer. 
The  pathologist,  Dr.  Stewart,  who  examined  the  speci- 
men, reported  that  there  was  a  gap  in  the  muscular  coat 
of  the  bowel  filled  with  scar  tissue,  the  probable  remains 
of  a  small   ulcer.      I    removed   the  appendix  also;     the 


Chronic  Duodenal  Ulcer  113 

patient  reported  himself  quite  well  eighteen  months 
later.  After  a  second  attack  I  have  operated  in  one 
case  and  excised  a  small,  quite  well-defined  ulcer.  In 
subsequent  attacks  the  ulcer  is  always  visible  or  palpable. 
A  patient  who  has  suffered  for  years  will  say  that  an 
"attack"  comes  on  as  a  result  of  exposure  to  cold,  or 
getting  the  feet  wet,  or  a  hasty  or  "indigestible"  meal, 
or  worry  or  overwork.  A  cause  can  almost  always  be 
assigned  for  the  onset  of  symptoms;  a  recurrence  of 
the  cause  is  usually  followed  by  a  reappearance  of  the 
symptoms.  The  most  common  of  all  these  causes  is 
"getting  cold";  in  consequence  the  great  majority  of 
the  patients  will  say  that  the  attacks  are  especially  prone 
to  come  in  the  winter  months — December,  January,  or 
February.  In  the  summer  the  symptoms  are  almost 
always  absent.  One  patient  of  mine  was  perfectly  well 
for  three  years  when  in  India.  He  returned  to  England 
in  November,  and  within  a  fortnight  had  "caught  a 
chill"  and  all  the  symptoms  returned.  In  several  cases 
I  have  known  an  attack  to  follow  close  upon  an  illness 
diagnosed  as  influenza,  and  in  a  few  cases  the  initial 
attack  has  so  occurred.  The  "attacks"  vary  in  length 
from  two  to  three  weeks  up  to  several  months.  It  is 
remarkable  that  an  attack  may  frequently  be  cut  short 
by  a  few  days.' rest  in  the  country  or  at  the  seaside.  Two 
of  my  patients,  medical  men,  told  me  that  a  long  "week- 
end" at  the  sea,  with  plenty  of  open-air  exercise,  free 
from  the  anxieties  of  practice,  would  always  cut  short 
an  attack  in  the  earlier  years  ol  their  trouble.  Both 
the  onset  and  the  termination  <>f  an  attack  may  be  quite 
sudden.  A  chill  may  bring  on  an  attack  in  a  tew  minutes, 
s 


ii4  Duodenal  Ulcer 

and  the  symptoms  may  continue  for  months.  In  more 
than  one  instance  I  have  known  the  symptoms  to  cease 
abruptly  when  the  patient  has  been  riding  or  has  been 
in  the  middle  of  a  game  of  golf,  or  taking  a  walk.  In 
the  end  the  pain  may  become  a  matter  of  daily  experi- 
ence, but  it  still  retains  its  characters  as  I  have  described 
them.  In  the  intervals  between  the  attacks  there  is 
complete  immunity  from  suffering,  food  is  taken  with 
full  enjoyment  and  with  keen  zest;  there  is  no  discom- 
fort of  any  kind ;  weight  is  gained,  and  mental  and  bodily 
vigour  are  at  their  highest.  So  complete  may  the  recov- 
ery be,  that  the  very  suggestion  that  the  former  attacks 
have  been  due  to  organic  disease  may  be  scouted  or 
received  with  the  tolerant  smile  of  disbelief.  The 
explanation  is  given  that  there  has  been  "hyperchlor- 
hydria"  or  that  the  case  is  one  of  "acid  dyspepsia"  or 
possibly  of  "neurosis."  The  idea  is  deep  rooted  that 
the  symptoms  are  always  due  to  an  excessive  acidity 
in  the  gastric  juice,  but,  as  I  shall  presently  shew,  there 
is  no  foundation  in  fact  for  this  venerable  fallacy. 

The  cause  of  "hunger  pain"  has  never  been  satis- 
factorily explained.  I  had  long  accepted  complacently 
the  statement  that  the  pain  began  at  the  time  when 
the  pylorus  relaxed  to  allow  of  the  food  passing  into  the 
duodenum;  that  the  pain  was  due,  that  is  to  say,  to 
contact,  the  surface  of  the  ulcer  being  chafed  or  fretted 
by  the  food  as  it  passed  onwards.  The  relief  from  pain 
which  followed  the  taking  of  food  or  an  alkali  was  held 
to  be  due  to  the  closure  of  the  pylorus  which  this  was 
supposed  necessarily  to  entail.  But  Dr.  Hertz  has 
recently  shewn  me  that  this  explanation  cannot  be  true; 


Chronic  Duodenal  Ulcer  115 

for  if  to  a  patient  suffering  from  duodenal  ulcer  (as 
subsequently  demonstrated  by  operation)  a  meal  be 
given  in  which  bismuth  has  been  mixed,  an  examination 
with  the  x-ray  screen  will  shew  that  food  begins  to  leave 
the  stomach,  and  to  pass  over  the  ulcer  into  the  duode- 
num within  the  first  few  minutes.  It  may,  indeed, 
often  appear  that  the  food  is  passed  from  the  stomach 
with  more  than  the  usual  rapidity.  The  pain  seems  to 
come  when  more  than  half  the  meal  has  left  the  stomach; 
it  cannot  therefore  be  due  to  any  lateral  movement  or 
disturbance  of  the  stomach,  due  to  its  full  or  empty 
state,  in  accordance  with  one  suggestion  which  has  been 
made;  for  the  pain  is  absent  if  the  stomach  is  kept  quite 
empty  for  several  hours,  and  when  present  is  almost 
instantly  abolished  by  the  taking  of  very  small  quantities 
of  food  or  alkalis.  It  would  seem  that  the  only  pos- 
sible  explanation  is  that  the  contents  of  the  stomach 
towards  the  end  of  digestion  possess,  for  some  reason,  a 
greater  acrimony  than  at  any  other  time.  It  may  only 
be  that  the  acid  content  is  then  greater,  or  it  may  be 
that  some  other  change,  of  which  at  present  we  know 
nothing,  has  taken  place.  And  it  is  probable  that  the 
pain  is  due  not  so  much  to  the  changes  in  the  chemical 
quality  of  the  chyme,  but  to  alterations  in  the  muscular 
activities  of  the  stomach  and  duodenum  to  which  those 
changes  are  the  stimulus. 

These  symptoms,  so  perfectly  characteristic  oi  duo- 
denal ulcer,  may  be  present  for  years  without  producing 
any  physical  signs.  It  is  therefore  not  necessary  to  the 
attaining  of  an  accurate  diagnosis  that  any  examination 
of  the  patient  be  made;    the  anamnesis  is  everything; 


n6  Duodenal  Ulcer 

the  physical  examination  is  relatively  nothing.*  There 
is,  in  the  stage  when  the  presence  of  the  ulcer  should  be 
recognised,  no  single  physical  sign  indicating  the  presence 
of  organic  disease.  Signs  which  confirm  the  accuracy 
of  the  diagnosis  may  appear  later,  but  there  is  no  need 
to  await  their  arrival  before  making,  as  we  ran  make 
with  the  utmost  confidence,  an  exact  diagnosis. 

In  a  large  number  of  cases  an  examination  of  the 
abdomen  reveals  no  abnormal  condition.  There  is 
perhaps  some  epigastric  tenderness  in  the  middle  line, 
or  to  the  right,  but  even  in  the  stages  of  active  ulcera- 
tion this  is  by  no  means  constant.  If  a  patient  be 
examined  during  the  time  that  he  is  suffering  pain,  say 
between  two  and  three  hours  after  a  meal,  when  the 
pain  is  probably  at  its  height,  there  is  usually  some 
tenderness,  which  may,  rarely,  be  exquisite.  It  is 
commonly  in  the  middle  line,  over  an  area  two  or  three 
inches  in  diameter.  In  a  very  few  cases  I  have  found 
that  the  patient  complains  of  pain  and  of  tenderness 
on  the  left  side;  and  no  explanation  of  this  anomaly 
appeared  at  the  time  of  operation.  When  pain  is  pres- 
ent and  acute,  the  right  epigastric  reflex  may  be  strongly 
accentuated;  in  the  same  patient  examined  when  no 
pain  is  present  the  reflex  of  the  two  sides  will  be  found 
equal.  Local  tenderness  is  generally  combined  with 
local   rigidity,   and   the  upper  part  of  the  right  rectus 

*  This  sentence  has  been  consistently  misrepresented  by  critics  whose 
only  desire  is  to  disagree.  It  does  not  mean,  and  cannot  easily  be  dis- 
torted to  mean,  even  when  divorced  from  its  context ,  that  t  he  patient  should 
not  be  examined.  But  it  does  state  and  is  intended  to  emphasise  the  un- 
doubted fact  that  the  presence  of  the  ulcer  itself,  apart  from  its  later  compli- 
cations, is  capable  of  clear  recognition  after  a  study  of  the  anamnesis  alone. 


Chronic  Duodenal  Ulcer  117 

muscle  may  be  firmly  contracted  and  tense.  The  con- 
trast between  the  muscles  of  the  two  sides  is  then  strik- 
ing. 

These  signs,  tenderness  in  the  mid-line  and  to  the 
right,  firm  contraction  with  rigidity  of  the  upper  part 
of  the  right  rectus,  and  a  briskness  of  the  right  epi- 
gastric reflex  are  the  only  signs  present  in  cases  of  duo- 
denal ulcer.  They  are  relatively  of  little  importance, 
for  they  are  found  in  a  well-marked  degree  only  in  a 
small  proportion  of  the  cases,  and  in  these  only,  as  a 
rule,  when  pain  is  present.  They  afford  perhaps  some 
slender  confirmation  of  the  diagnosis,  but  in  them- 
selves, apart  from  the  clinical  history,  are  of  no  sub- 
stantial value.  In  the  later  stages  of  duodenal  ulcer, 
when  stenosis  has  occurred,  the  usual  signs  of  a  dilated 
and  obstructed  stomach  are  present. 

It  is  therefore  chiefly,  indeed  as  a  rule  quite  exclu- 
sively, upon  the  anamnesis,  that  the  diagnosis  of  duo- 
denal ulcer  is  made. 

In  a  rather  later  stage  dilatation  of  the  stomach,  with 
motor  incompetence,  may  appear.  The  stomach,  that 
is  to  say,  is  unable  to  empty  itself  completely  within  the 
normal  period  of  time.  What  should  be  considered  a 
"normal  period"  is  not  agreed  upon  by  all  writers.  I 
have  arbitrarily  adopted  the  period  of  twelve  hour-. 
If  a  stomach  is  not  able  to  empty  i t -.  contents  into  the 
duodenum  within  twelve  hour-,  it  is  very  probable  that 
there  is  organic  disease  which  prevents  it  doing  so. 
Gastric  ->ta>i>  then  may  be  found  in  cases  of  duodenal 
ulcer;  it  is  due  always  to  the  narrowing  which  occurs 
by  reason  of  the  healing,  partial,  as  a  rule,  but  some- 


n8  Duodenal  Ulcer 

times  complete,  of  the  ulcer  or  ulcers.  I  have  never 
found  that  stasis  of  this  degree  was  present  as  a  result 
of  pyloric  spasm.  It  is  possible  that  a  spasm  of'  the 
pylorus  prevents  the  stomach  from  emptying  as  quickly 
as  it  otherwise  would  do ;  for  the  spasm  no  doubt  exists 
because  of  the  need  for  protection  of  the  ulcer  of  the 
duodenum  from  the  harm  which  contact  with  the  acid 
chyme  would  inflict.  The  spasm  is  reflex  and  is  pro- 
tective, as  was  so  beautifully  shewn  by  Cannon  and 
Murphy  ("Annals  of  Surgery,"  1906,  vol.  xliii,  512). 
But  a  spasmodic  contraction  of  the  muscle  which  guards 
the  outlet  does  not  prevent  the  stomach  from  emptying 
within  the  period  of  twelve  hours.  Its  occurrence  is 
probably  protective  also  in  the  fact  that  it  arouses 
symptoms  the  mere  presence  of  which  makes  the  patient 
less  eager  to  take  food  in  full  quantities.  Gastric  stasis 
denotes,  therefore,  the  existence  of  a  narrowing  in  the 
duodenum  due  to  organic  disease.  When  this  narrow- 
ing attains  even  a  very  moderate  degree,  an  hyper- 
trophy of  the  musculature  of  the  stomach  develops,  as 
always  happens  in  the  alimentary  canal;  and  the  evi- 
dence of  this  may  be  found  in  the  peristaltic  waves  seen 
when  the  stomach  is  examined.  If  the  stomach  is 
empty  or  only  partially  filled,  these  muscular  contrac- 
tions may  not  be  seen,  but  the  administration  of  the 
two  halves  of  a  Seidlitz  powder  separately  will  soon 
excite  them. 

In  all  cases  of  duodenal  ulcer,  indeed,  in  all  eases  oi 
intractable  stomach  disorder,  a  test  meal  should  be 
given.  There  are  a  number,  by  no  means  inconsiderable, 
of  patients  who  have  been   referred   to  me  as  cases  of 


Chronic  Duodenal  Ulcer  119 

"hyperacidity,"  "acid  gastritis,"  upon  whom  I  have 
operated  and  have  demonstrated  the  existence  of  a 
duodenal  ulcer.  Recurrent  severe  "hyperchlorhydria"* 
is  duodenal  ulcer.  The  symptoms  of  which  the  patient 
makes  complaint  are  ascribed  to  hyperacidity;  but  it 
is  extremely  interesting  to  know  that  it  is  not  infrequent 
for  the  gastric  juice  in  such  cases  to  contain  less  free 
HC1  than  the  normal. 

The  relationship  of  "hyperchlorhydria"  to  duodenal 
ulcer  has  given  rise  to  a  great  deal  of  discussion.  The 
term  "hyperchlorhydria"  should  indicate,  of  course, 
the  "increased  secretion  of  gastric  juice,  or,  better,  of 
hydrochloric  acid,  during  digestion"  (Riegel).  The  true 
nature  of  the  disease  is  the  increased  secretion  of  hydro- 
chloric acid  at  the  time  of  digestion.  Every  physician 
who  has  written  upon  diseases  of  the  stomach  up  to  the 
present  day  believed  that  "hyperchlorhydria"  was  a 
functional  disorder.  Certain  symptoms  were  ascribed 
to  this  condition  of  increased  secretion.  By  degrees  it 
became  customary  to  apply  the  diagnosis  "hyperchlor- 
hydria" to  those  patients  who  presented  these  symp- 
toms. So  that  the  term  at  first  introduced  to  indicate 
a  condition  of  the  gastric  secretions  found  upon  exami- 
nation of  the  stomach  contents  lost  this  purely  chemical 
meaning  and  took  on  a  clinical  significance.  If,  now, 
we  read  the  work  of  one  of  the  greatest  authorities 
Riegel  (see  "Diseases  of  the  Stomach,"  American 
edition,  W.  B.  Saunders  &  Co.,   1903,  pp.  299  et  seq.), 

*  The  term  "  hyperchlorhydria  "  is  here  pu1  in  inverted  commas  to  indi- 
cate thai  it  is  used  in  the  sense  in  which  English  physicians  are  accustomed 

in  use  it ,  ili.  1 1  is,  in  .1  '  linn  .il  sense  and  no1  .1-  .1  term  in  chemistry. 


120  Duodenal  Ulcer 

we  shall  find  a  very  detailed  description  given  of  the 
symptom-complex  attributed  to  "hyperchlorhydria." 
I  believe  that  a  perfectly  dispassionate  reader  must  be 
convinced,  by  a  study  of  this  chapter,  that  Riegel  is  in 
reality  describing,  not  a  functional  disorder,  but  a 
genuine  organic  disease,  duodenal  ulcer.  When  we 
return  to  his  description  of  duodenal  ulcer  (p.  614),  it 
seems,  beyond  doubt  or  dispute,  quite  certain  that 
Riegel  knows  little  of  this  disorder.  His  description 
is  meagre  and  inaccurate  or  inadequate  in  almost  every 
particular.  Of  the  relationship  of  hyperacidity  to 
duodenal  ulcer  he  is  in  doubt,  for  he  writes:  "It  has 
not  been  determined  whether  or  not  hyperacidity  also 
occurs  in  ulcer  of  the  duodenum.  I  have  succeeded 
in  finding  only  one  direct  statement  in  this  respect  in 
Leube's  work.  This  author  reports  a  case  of  ulcer  of 
the  duodenum  that  terminated  fatally  from  haemorrhage 
and  in  which  the  value  for  hydrochloric  acid  equalled 
0.16  percent.;  in  which,  in  other  words,  there  was  no 
hyperacidity." 

When  I  first  began  to  disentangle  the  authentic 
symptoms  of  duodenal  ulcer,  and  by  degrees  to  recognise 
clearly  the  well-defined  clinical  picture  of  this  disease, 
1  was  struck  with  the  similarity,  indeed  in  many  respects 
the  identity,  of  the  symptoms  recited  to  me  by  the 
patients  to  those  described  by  the  most  authoritative 
writers  on  medicine  as  due  to  "hyperchlorhydria." 
And  when,  repeatedly,  I  found  that  cases  diagnosed  by 
physicians  of  the  first  rank,  well  versed  in  the  literature 
and  of  much  practical  experience,  as  "hyperchlorhydria" 
were  in  fact  cases  of  duodenal  ulcer,  and  would  so  be 


Chronic  Duodenal  Ulcer  121 

demonstrated  upon  the  operation  table,  I  felt  entitled 
to  claim  that  in  the  diagnosis  of  such  cases  the  physician 
was  speaking  of  fancies  and  the  surgeon  of  facts.  And 
when,  further,  it  was  found  that  in  a  series  of  such 
cases  an  excess  of  free  HC1  was  not  present  in  the  major- 
ity it  became  quite  certain  that  there  had  been  con- 
fusion not  only  in  terms,  but  in  the  whole  conception  of 
the  cases.  A  genuine  organic  disease  was  miscalled 
"functional."  My  own  experience  of  the  relationship 
of  hyperacidity  to  duodenal  ulcer  in  all  the  phases  in 
which  we  meet  it  upon  the  operation  table,  from  early 
active  ulceration  to  the  final  cicatricial  stenosis,  is  roughly 
this,  that  in  about  40  per  cent,  of  the  cases  free  HC1  is  in 
excess,  in  40  per  cent,  it  is  approximately  normal,  and  in 
20  per  cent,  it  is  well  below  the  normal.  It  chanced  that 
in  18  successive  cases  recently  there  was  not  one  in 
which  free  HC1  was  excessive.  It  may  well  be  that 
there  is  a  geographical  factor  in  the  different  experi- 
ences of  different  authors  in  their  examinations  of  the 
amount  of  free  HC1.  Dr.  Hertz  has  drawn  my  attention 
to  the  fact  that  at  the  discussion  on  the  treatment  of 
gastric  ulcer  at  the  German  Congress  for  Internal  Medi- 
cine held  in  Wiesbaden  in  1909  Lenhartz  of  Hamburg, 
von  M  tiller  of  Munich,  and  von  Krehl  of  Heidelberg, 
laid  stress  upon  the  differences  in  the  results  of  analysis 
of  the  gastric  juice,  in  patients  suffering  from  gastric 
ulcer,  in  different  localities.  In  Munich,  for  example, 
hyperacidity  is  exceptional,  and  in  at  leasl  20  per  cent. 
of  tin-  cases  there  i>  hypochlorhydria.  In  North  Ger- 
many, on  the  oilier  hand,  hyperchlorhydria  is  almost 
constantly  present   in  gastric  ulcer.     In   France,  or,  at 


122  Duodenal  Ulcer 

any  rate,  in  Paris,  hyperchlorhydria  appears  to  be 
almost  constantly  present  in  gastric  ulcer  ("Verhand. 
des  Kongr.  f.  inn.  Medizin,"  1909). 

Dr.  G.  A.  Gibson  ("Edin.  Med.  Jour.,"  191 1,  vi, 
325)  mentions  a  series  of  cases  of  duodenal  ulcer  proved 
by  operation  in  which  he  found  that  the  total  acidity 
varied  from  0.01  per  cent,  to  0.26  per  cent.  The  amount 
of  free  acid  varied  between  0.02  (very  small)  and  0.18 
(extremely  high) ;  so  that  Dr.  Gibson's  experience 
shews  that  "in  undoubted  duodenal  ulcer  the  condition 
of  acidity  in  the  stomach  varies  within  wide  limits." 

J.  C.  Adams  ("Thesis  on  Duodenal  Ulcer,"  Belfast, 
191 1 )  made  "an  accurate  gastric  analysis  in  20  cases 
of  duodenal  ulcer.  In  14  the  total  acidity  averaged 
96  per  cent,  and  the  free  HC1  ranged  from  0.21  to  0.27. 
Hence  in  70  per  cent,  of  the  cases  there  was  distinct 
hyperchlorhydria.  In  the  other  30  per  cent,  the  acidity 
was  about  normal,  and  in  two  of  the  cases  was  under 
normal  in  amount." 

It  is  now  well  known  that  hyperacidity  may  be  pres- 
ent when  symptoms  quite  different  from  those  described 
by  Riegel  are  elicited  in  the  history,  or  even  when  no 
gastric  symptoms  whatever  are  present.  Hyperchlor- 
hydria is  found,  fleetingly,  in  cases  of  cholelithiasis;  it 
is  present  in  cases  of  gastric  ulcer,  of  colitis,  of  tuber- 
culous disease  of  the  intestine  and  of  the  mesenteric 
glands  and  of  appendicitis.  H.  J.  Paterson,  who  has 
devoted  much  attention  to  the  gastric  chemistry  in 
cases  requiring  surgical  treatment,  writes  that  he  has 
"operated  on  nearly  50  cases  of  hyperchlorhydria  and 
in  every  one  of  them  there  was  an  organic  lesion  either 


Chronic  Duodenal  Ulcer  123 

of  the  stomach,  duodenum,  gall-bladder,  or  appendix" 
("Trans.  Roy.  Soc.  Med.,"   1910,  iii,   108). 

I  have  no  doubt  that  the  different  disclosures  as  to 
the  quantity  of  free  or  active  HC1  in  the  stomach  con- 
tents related  by  various  observers  may  be  in  part  due 
to  the  different  stages  of  the  disease  in  which  the  exami- 
nations are  conducted.  If  the  ulcer  is  active,  the 
patient  being  in  the  fury  of  one  of  his  "attacks,"  free 
HC1  is  probably  present  in  excess  in  the  majority  of 
the  cases.  If  the  "attack"  is  over,  or  if  the  symptoms 
the  patient  presents  are  those  of  a  stenosis  which  has 
at  last  developed  at  the  site  of  a  chronic  ulcer,  then 
the  free  HC1  may  be  diminished  or  be  absent.  To  sa} 
the  truth,  the  results  of  the  ehejnical  examination  of 
the  stomach  contents  in  cases  of  duodenal  ulcer  art' 
rarely  of  any  value.  The  majority  of  my  cases  still 
have  test-meals  given,  and  the  stomach  contents  are 
then  examined.  For  two  or  three  years  every  case 
without  exception  was  submitted  to  this  ordeal.  But 
the  results  really  do  not  help  one  to  gain  any  opinion 
more  accurate  than  that  which  is  procured  after  a  close 
study  of  the  anamnesis  alone 

The  whole  question  may,  I  think,  be  summed  up  in 
this  way:  Hyperchlorhydria,  a  term  which  has  been 
debased  and  shorn  of  it--  original  significance,  should 
not  be  used  in  a  clinical  sense,  but  should  be  held  strictly 
to  indicate  the  excess  of  active  hydrochloric  acid  in  the 
stomach  contents  (see  Willcox,  "Quarterly  Journal  of 
Medicine,"  [909,  iii.  9).  Hyperchlorhydria  is  present 
in  mosl  cases  of  duodenal  ulcer  during  the  active  stage 
of  ulceration.     There  may  be  hypochlorhydria  in  ca 


124  Duodenal  Ulcer 

of  duodenal  stenosis,  in  the  intervals  between  "attacks," 
or  rarely  in  the  acute  phases  of  ulceration.  There  are 
probably  geographical  differences  in  the  frequency  and 
severity  of  hyperchlorhydria  in  cases  of  duodenal  and 
gastric  ulcer.  Hyperchlorhydria  is  present  in  other 
diseases,  notably  cholelithiasis  and  appendicitis,  and  its 
presence  probably  explains  the  mimicry  of  the  symptoms 
of  duodenal  ulcer  by  these  various  diseases.  The 
chief  diagnostic  importance  of  hyperchlorhydria  is  in 
cases  of  carcinoma  of  the  stomach.  The  persistent 
presence  of  an  excess  of  active  hydrochloric  acid  in  the 
stomach  contents  is  indicative  of  an  organic  rather 
than  a  functional  disorder, 

A  sign  which  sometimes  appears  early  in  the  course 
of  this  disease,  which  may,  indeed,  be  the  initial  sign, 
but  which  is  more  often  a  late  symptom,  is  haemorrhage. 
It  is,  generally,  an  evidence  that  the  process  of  ulcer- 
ation has  extended  to  such  a  depth  as  to  open  up  a 
large  vessel,  and  so  deep  an  invasion  of  the  coats  of  the 
bowel  is  usually  accomplished  only  after  the  lapse  of 
months  or  of  years.  When  bleeding  occurs,  in  a  quantity 
sufficient  for  it  to  be  recognised  as  haematemesis  or 
melaena,  it  is  with  few  exceptions  an  evidence  of  the 
deep  penetration  of  the  walls  of  the  duodenum  by  an 
ulcer  whose  existence  should  have  been  recognised  long 
ago.  Neither  haematemesis  nor  melaena  should  be  con- 
sidered as  among  the  usual  signs  of  duodenal  ulcer; 
they  are  both  complications  whose  onset  should  have 
been  ton-tailed;  they  are  a  witness  to  neglected  oppor- 
tunities. 

The    frequency   with    which    bleeding   occurs   from   a 


Chronic  Duodenal  Ulcer  125 

duodenal  ulcer  has  been  variously  estimated  by  different 
authorities.  Thus  Krauss  in  the  70  cases  collected  by 
him  found  that  in  20  free  haemorrhage  had  been  observed. 
Oppenheimer  in  "over  100"  cases  found  bleeding  re- 
corded in  34.  In  Perry  and  Shaw's  series  of  60  cases  pre- 
senting symptoms  in  a  total  of  151  cases,  haematemesis 
or  melaena  was  present  in  23.  Xine  patients  had  haemat- 
emesis, nine  had  melaena,  and  five  had  both  haemateme- 
sis and  melaena.  In  Xothnagel's  Encyclopedia  (p.  245) 
it  is  said  that  "severe  haemorrhage  occurs  in  about  one- 
third  of  cases."  Fenwick  estimates  the  frequency  of 
haemorrhage  in  acute  cases  at  26  per  cent.,  or  in  chronic- 
cases  at  40  per  cent. 

All  these  figures  seem  to  me  to-  be  valueless.  They 
are  compiled  from  statistics  every  item  in  which  is  open 
to  disproof  or  doubt.  The  symptoms  which  characterise 
duodenal  ulcer  so  unmistakably  were  unknown  to  every- 
one of  these  authorities;  the  frequency  of  the  din 
was  therefore  quite  unappreciated.  Only  patients  who 
suffer  from  such  complications  as  stenosis,  perforation, 
or  haemorrhage  were  known  to  suffer  from  an  ulcer  in 
the  duodenum,  and  the  verification  of  the  diagnosis 
could  only  then  be  made  upon  the  post-mortem  table. 
In  my  own  series  of  cases  haemorrhage  has  been  noticed 
in  37.6  per  cent.  Bui  with  the  new  light  which  has  now 
been  -lied  upon  this  important  subject  by  the  work  of 
the  surgeon,  we  have  conic  to  recognise  that  haemor- 
rhage is  not  a  symptom,  but  a  late  complication;  that 
it-  onsel  IS  not  to  be  awaited  in  order  that  a  doubtful 
diagnosis  may  receive  confirmation,  but  that  its  appear- 
ance is  to  be  prevented  by  a  timely  recognition  <>l  the 


126  Duodenal  Ulcer 

significance  of  the  early  symptoms.  Haemorrhage,  when 
it  does  oceur,  may  be  manifest  either  as  haematemesis 
or  as  melaena;  the  blood  may  be  discharged  in  the  vomit 
or  in  the  faeces.  Melaena  may,  and  indeed  usually  does, 
exist  without  haematemesis,  but  when  blood  is  vomited 
there  is  almost  without  exception  some  blood  also  in 
the  stools.  I  believe  haemorrhage  from  a  duodenal  ulcer 
to  be  a  sign  of  grave  significance,  of  far  more  serious 
import  than  bleeding  from  a  gastric  ulcer.  In  the  latter 
death  very  rarely  occurs;  in  the  former  it  is  more  fre- 
quent than  is  generally  supposed.  I  "have  thrice  had 
the  experience  of  advising  operation  for  duodenal  ulcer 
in  cases  where  haemorrhage  subsequently  occurred  and 
proved  fatal  before  surgical  help  could  be  given.  Haem- 
orrhage from  a  "gastric  ulcer"  is  sometimes  very  copi- 
ous and  gives  rise  to  great  alarm,  but  when  the  bleeding 
ceases  spontaneously,  the  patient  recovers  quickly.  In 
duodenal  ulcer  the  bleeding  causes  faintness  and  anaemia, 
the  exact  origin  of  which  may  not  be  obvious  till  the 
bowels  are  moved.  Then  faintness  and  prostration  come 
again  and  again;  an  abundance  of  blood,  at  first  black, 
but  later  of  a  brighter  hue,  is  passed,  and  the  patient 
may  rapidly  become  exsanguine  and  die.  The  manner 
in  which  haemorrhage  appears  varies  much  in  different 
cases.  As  a  rule,  there  is  a  considerable  exacerbation 
in  the  symptoms  before  the  bleeding  comes;  the  "in- 
digestion" is  more  acute,  the  feeling  of  distension  or 
oppression  after  food  is  greater,  and  the  patient  himself 
does  not  feel  so  well.  Then  suddenly  be  becomes  faint 
and  weak  and  breathless,  the  head  feels  light  and  "swim- 
ming," and  the  sight  seems  quickly  to  grow  dim.     The 


Chronic  Duodenal  Ulcer  127 

patient  looks  white,  his  lips  are  bloodless,  and  sweat 
covers  the  brow ;  he  asks  constantly  for  air  and  is  breath- 
less; he  displays,  in  brief,  all  the  classical  signs  of  an 
internal  haemorrhage.  That  this  has  occurred  is  pres- 
ently made  certain  by  the  voiding  of  blood  in  the  char- 
acteristic "tarry"  motions  or  by  the  ejection  of  brighter 
blood  in  the  vomit. 

In  other  cases  the  haemorrhage  may  occur  insidiously, 
without  the  patient  having  noticed  it:  he  is  aware  only 
of  a  continuing,  weakness  and  frailty  which  he  can  hardly 
understand.  A  case  in  my  own  series  was  an  exemplary 
instance  of  this.  The  man  was  sent  to  me  because  of  a 
right  inguinal  hernia.  As  he  entered  my  room  I  was 
struck  with  his  blanched  appearance.  When  I  asked 
him  to  tell  me  his  symptoms,  he  had  nothing  to  say 
but  that  he  had  a  hernia.  I  asked  if  he  had  noticed 
any  loss  of  blood;  he  replied  in  the  negative.  I  enquired 
whether  "indigestion"  had  been  observed,  and  he  said 
at  once  that  he  had  "suffered  from  that  for  years,"  and 
that  recently  it  had  been  very  severe.  I  took  the  man 
into  hospital  and  found  that  he  had  melaena.  I  elicited 
thru  a  perfectly  clear  history  of  duodenal  ulcer,  for 
which  I  performed  gastroenterostomy.  The  case  has 
been   very  successful   (No.  46). 

It  is  probable  that  a  certain  degree  of  haemorrhage 
occurs  in  main-  cases  of  duodenal  ulcer  without  being 
recognised.  The  surface  of  the  ulcer,  when  fretted. 
probably  bleeds  a  little,  and  if  the  stools  were  carefully 
and  regularly  examined,  traces  of  occult  blood  would 
surely  be  found.  I  have  in  a  few  cases  found  this  to  be 
the  case,  but  since  I   have  realised  how  accurately  the 


128  Duodenal  Ulcer 

existence  of  an  ulcer  can  be  recognised  from  a  study  of 
the  clinical  symptoms  alone,  I  have  not  pursued  this 
line  of  investigation  closely.  Occult  blood,  blood  that 
is  in  quantities  too  small  to  be  seen  by  the  naked  eye, 
but  capable  of  recognition  by  other  tests,  is  therefore 
probably  very  frequent. 

In  order  to  obtain  some  idea  of  the  frequency  of  the 
passage  of  occult  blood  I  have  had  20  cases  in  succession 
examined  during  the  course  of  this  year  (191 1).  In  all  a 
duodenal  ulcer  was  diagnosed,  in  all  one  or  more  ulcers 
were  found  at  the  time  of  the  operation.  The  faeces  were 
examined  in  every  case  by  Dr.  M.  J.  Stewart.  In  10 
cases  blood  was  found  in  the  faeces;  in  2  of  these  it  was 
plainly  visible  to  the  naked  eye.  In  10  cases  it  was 
reported  that  no  blood  was  present;  in  three  of  these 
a  history  of  melaena  was  given  by  the  patient  of  his 
medical  man.  It  is  probable,  however,  that  in  cases  of 
active  ulceration  in  the  duodenum  a  daily  examination 
of  the  stools  would  reveal  the  frequent  if  not  constant 
presence  of  blood.  Dr.  Craven  Moore  has  found  occult 
blood  in  100  per  cent,  of  his  personal  cases. 

The  vessels  which  are  opened  by  the  deep  invasion 
of  the  walls  of  the  bowel  by  the  ulcer  vary  considerably 
in  size;  in  proportion  to  their  size  the  haemorrhage  is 
slight  or  abundant.  The  following  are  some  of  the 
larger  vessels  which  have  been  eroded,  with  the  result 
that  fatal  haemorrhage  has  occurred:  the  aorta;  the 
hepatic,  gastroduodenal,  superior  pancreatico-duodenal, 
right  gastro-epiploic,  and  pyloric  arteries;  the  portal 
and  superior  mesenteric  veins.  In  a  few  cases  haemor- 
rhage has  been  so  sudden  in  onset  and  so  profuse  as  to 


Chronic  Duodenal  Ulcer  129 

cause  death,  which  was  almost  instantaneous.  When 
the  base  of  an  ulcer  from  which  fatal  haemorrhage  has 
occurred  comes  to  be  examined,  the  vessel  involved  is 
usually  found  to  have  thick  and  rigid  walls.  The 
opening  from  which  the  blood  has  come  is  at  the  side  of 
the  artery,  which  remains  wide  open.  There  is  neither 
closure  nor  retraction  of  the  vessel,  whose  walls,  stiff  as 
the  stem  of  a  clay  pipe,  seem  incapable  of  contraction. 
Such  is  a  brief  description  of  the  characteristic  symp- 
toms of  chronic  duodenal  ulcer.  If  a  patient  presents 
these  symptoms,  the  diagnosis  of  duodenal  ulcer  may 
confidently  be  entertained.  There  is  no  need  for  further 
evidence  than  that  which  is  so  afforded.  I  constantly 
operate  upon  the  strength  of  the  history  alone,  and  as 
often  do  I  demonstrate  the  existence  of  a  chronic  ulcer, 
a  tangible  or  visible  lesion,  as  the  cause  of  the  symptoms. 
Of  nothing  concerned  with  the  relationship  between 
altered  structure  and  altered  function  am  I  so  convinced 
as  that  symptoms  such  as  I  have  portrayed  owe  their 
origin  to,  and  are  dependent  for  their  perpetuation  and 
their  periodic  repetition  upon,  a  chronic  duodenal  ulcer. 
A  description  of  these  symptoms  is  to  be  met  with  in 
most  of  the  text-books  of  medicine,  under  the  caption 
"hyperchlorhydria"  or  "acid  gastritis,"  and  the  belief 
that  these  words  are  a  sufficient  diagnosis  is  very  general. 
After  giving  a  diagnosis  of  duodenal  ulcer,  I  am  not 
infrequently  met  with  the  objection  that  the  patient's 
symptoms  are  indicative  of  nothing  more  than  "per- 
sistent hyperchlorhydria."  This  in  England  is  the 
medical  term  for  the  surgical  condition  duodenal  ulcer. 
The  symptoms  of  "acid  dyspepsia,"  if  they  are  intract- 
9 


130  Duodenal  Ulcer 

able  and  recurrent,  are  due  to  the  demonstrable  lesion, 
duodenal  ulcer.  Of  that  there  can  no  longer  be  any 
doubt.  The  most  interesting  feature,  however,  in  such 
cases  is  that  an  excess  of  free  hydrochloric  acid  is  not 
present,  as  a  rule;  indeed,  it  is  exceptional  to  find  any 
greatly  increased  acidity.  This  is  well  shewn  in  the 
reference  given  elsewhere  to  a  series  of  examinations 
of  the  gastric  juice  made  upon  consecutive  cases  sub- 
mitted to  operation,  many  of  which  had  borne  the 
clinical  label  "hyperacidity"  for  months  or  years.  It 
is  true  that  in  such  cases  an  "acid  rising"  occurs; 
chyme  brought  up  into  the  mouth  burns  the  oesophagus 
and  the  pharynx,  makes  the  mouth  hot,  and  the  teeth 
to  feel  "chalky."  But  chyme  is  naturally  acid;  it  is 
the  regurgitation  which  is  abnormal.  The  acidity  of 
the  stomach  contents  when  brought  back  in  the  act 
of  vomiting  some  time  after  a  meal  is  well  known,  and 
the  effect  on  the  teeth  and  the  buccal  mucous  mem- 
brane is  similar  to  that  found  in  "acid  dyspepsia."  In 
cases  of  "hyperchlorhydria"  this  constant  regurgitation 
of  acid  chyme  is  probably  due  to  the  fact  that  a  protec- 
tive spasm  of  the  pylorus  is  present,  and  that  the  stomach 
contents,  hindered  or  retarded  in  their  onward  pro- 
gression, are  eager  to  find  the  only  other  means  of 
escape  from  the  stomach. 

The  terms  '-'acid  dyspepsia,"  "hyperacidity,"  "hyper- 
chlorhydria," are  then  not  only  dangerous  as  concealing 
the  fact  that  the  condition  which  causes  them  is  not 
functional,  as  is  implied,  but  organic;  but  they  are 
misnomers  also,  for  the  presence  of  an  excess  of  acid  is 
not  constant. 


Chronic  Duodenal  Ulcer  131 

The  description  I  have  given  applies  to  the  great 
majority  of  the  cases  of  chronic  duodenal  ulcer,  but 
there  are  certain  variations  of  type,  which,  though  excep- 
tional, are  important,  and  should  be  recognised.  For 
example,  there  are  cases  in  which  a  chronic  duodenal 
ulcer  is  afterwards  found  in  which  all  symptoms  and 
signs  are  quite  insignificant  in  comparison  with  haemor- 
rhage. A  patient  of  my  own  (case  114)  had  suffered  in 
only  the  slightest  degree  from  a  little  flatulence  and 
indigestion  about  a  year  before  I  saw  him.  For  several 
months  he  was  free  from  all  pain  or  discomfort.  Sud- 
denly one  evening,  while  at  his  club,  he  fainted,  and 
haematemesis  occurred,  to  be  followed  by  melaena,  which 
persisted  without  interruption,  though  in  varying  quan- 
tity, for  ten  weeks.  Even  during  this  period  the  fluid 
food  he  took  caused  no  distress.  I  feared,  and  so  also 
did  I  )r.  Malim,  who  referred  the  patient  to  me,  that 
unless  the  bleeding  was  checked  the  severe  and  unceas- 
ing anaemia  would  end  in  death.  I  operated  and  found 
a  small  duodenal  ulcer  which  I  excised;  at  its  base  a 
small  artery  was  eroded.  Similar  cases,  though  non< 
striking,  have  occurred,  to  the  number  of  five.  In  all 
hemorrhage  overshadowed  all  other  symptoms,  and 
added  to  them  a  significance  which  was  unmistakable. 
In  a  case  operated  upon  in  190';  almost  fatal  haemorrhage 
had  occurred  twice  during  a  period  when  other  symptoms 
were  very  slight.  The  patient  had,  however,  taken 
almost  no  solid  food  for  two  and  one-halt"  years.  Three 
small  ulcers  were  found  on  the  .interior  wall  of  the 
duodenum. 

In  several  cases  the  haemorrhage,  which  has  produced 


132  Duodenal  Ulcer 

profound  anaemia,  lassitude,  weakness,  and  breathless- 
ness,  may  have  escaped  notice.  One  of  my  very  early 
cases  had  repeated  sudden  attacks  of  faintness,  pallor, 
and  enduring  anaemia,  with  only  very  trivial  indigestion. 
Until  he  was  by  chance  confined  to  bed  it  was  not  recog- 
nised that  the  stools  were  black  and  tarn7.  A  close 
enquiry  was  then  made  into  the  history,  a  diagnosis  of 
duodenal  ulcer  made  by  Dr.  G.  P.  Anning,  and  an  oper- 
ation undertaken.  In  a  certain  group  of  cases,  then, 
haemorrhage  may  be  predominant  over  all  other  signs 
or  symptoms. 

There  is  a  small  group  of  cases  in  which  the  symp- 
toms of  active  ulceration  are  almost  completely  latent, 
and  the  patient  first  consults  his  medical  man  because 
of  repeated  and  copious  vomiting,  which  is  found  to  be 
due  to  an  obstruction  near  the  pylorus.  The  first  pro- 
nounced symptoms  are  due  not  to  the  ulcer,  but  to  the 
stenosis  which  has  insidiously  developed  in  the  scar. 
On  enquiring  closely  into  the  history  of  all  these  cases 
I  have  found  that  symptoms  of  "indigestion"  have  been 
present  in  the  earlier  years,  but  that  they  have  been  kept 
in  subjection  either  by  the  most  sedulous  attention  to 
the  diet,  by  constant  draughts  of  a  bismuth  and  mor- 
phine mixture,  or  by  repeated  doses  of  carbonate  of 
soda,  or  by  lavage  of  the  stomach.  So  easily  are  the 
symptoms  kept  in  check  by  one  means  or  another  that 
the  remembrance  of  their  character,  or  even  of  their 
occurrence,  may  have  faded  from  the  patient's  mind. 
The  stricture  which  at  last  results  may  be  as  thin  as 
whip-cord,  or  may  be  caused  by  a  hard  fibrous  mass  the' 
size  of  a  golf  ball.      In  all  the  cases  within  this  group 


Chronic  Duodenal  Ulcer  133 

the  symptoms  of  the  ulcer  are  overshadowed  by  the 
signs  due  to  the  scar  which  results  from  its  healing. 
It  is  in  cases  of  this  kind  that  there  may  be  great  diffi- 
culty in  deciding  whether  the  bleeding  is  due  to  a  duo- 
denal ulcer  or  is  one  of  the  manifestations  of  Band's 
disease. 

There  is  a  type  less  frequent  than  the  above,  and  more 
baffling  to  the  diagnostician,  in  which  little  can  be 
elicited  except  a  complaint  of  "acidity."  Many  of  the 
patients  complain  of  "heartburn,"  " waterbrash,"  or 
"aridity,"  but,  as  a  rule,  these  symptoms  are  trivial  in 
comparison  with  the  real  pain  which  the  patients  suffer. 
In  very  rare  cases,  however,  the  intensity  of  the  acid 
regurgitation  may  be  such  that  all  other  troubles  seem 
by  comparison  insignificant.  The  most  exemplary  in- 
stance of  this,  within  my  own  experience,  occurred  in 
the  case  of  a  medical  man,  who  had  suffered  for  twenty 
years.  His  chief  complaint  was  of  incessant  and  intol- 
erable acidity,  and  it  required  a  close  investigation  of 
his  very  early  history  to  extract  a  clear  account  of 
"hunger  pain."  For  years  he  had  washed  the  stomach 
out  often  two  or  three  hours  after  a  meal,  not  because  of 
pain  or  distress,  but  solely  because  the  acid  waterbrash 
was  so  unpleasant.  The  stomach  contents  after  test 
meals  shewed  only  a  little  more  than  half  the  normal 
acidity,  and  at  the  operation  the  cheloid  scar  of  a  chronic 
ulcer  was  found  in  the  duodenum.     (No.  17s. 

During  the  last  two  years  the  majority  of  my  cases  of 
duodenal  ulcer  have  been  examined  by  the  x-rays  after 
the  administration  of  a  meal  of  bismuth,  with  milk,  or 
bread  and  milk.     The  results  which  Dr.  L.  A.  Rowden 


134  Duodenal  Ulcer 

has  obtained  have  been  interesting.  As  a  rule,  in 
uncomplicated  cases  of  duodenal  ulcer,  that  is,  in  cases 
where  obstruction  has  not  yet  developed,  a  most  strik- 
ing spectacle  is  afforded  by  the  greatly  increased  activity 
of  the  stomach.  Food  begins  to  pass  into  the  duodenum 
at  once,  and  continues  to  pass  with  greater  rapidity 
than  in  the  normal  condition.  By  the  time  the  pain 
begins  to  appear  the  stomach  is  nearly  empty,  and 
most  of  the  bismuth  has  left  the  duodenum  and  can  be 
seen  in  the  small  intestine.  The  muscular  activity 
of  the  pyloric  portion  of  the  stomach  is  exalted.  In  a 
few  cases  a  local  arrest  of  the  bismuth  in  the  first  por- 
tion of  the  duodenum  has  led  Dr.  Rowden  correctly  to 
predict  the  presence  of  a  pouch  caused  by  the  distorted 
contraction  of  an  ulcer.  In  four  or  five  patients  only  the 
whole  duodenum  has  seemed  to  empty  slowly,  and  this 
has  been  the  case  chiefly  when  a  rather  larger  dose 
(more  than  three  ounces)  of  bismuth  has  been  given 
and  the  patient  has  been  examined  only  in  the  recumbent 
position.  When  stasis  is  present,  as  a  consequence  of 
the  narrowing  of  the  duodenum,  the  meal  is  seen  to 
leave  the  stomach  very  slowly;  in  severe  cases  a  shadow 
may  be  seen  even  at  the  end  of  eighteen  or  twenty-four 
hours. 

Dr.  Hertz,  at  whose  instigation  we  began  systemati- 
cally to  examine  our  patients  in  this  wray,  writes  ("The 
Sensibility  of  the  Alimentary  Canal,"  191 1,  59): 

"In  a  series  of  cases  of  duodenal  ulcer  examined  with  the 
x-rays.  I  have  always  found  that  the  stomach  begins  to  empty 
itself  immediately  after  the  food  has  been  swallowed  and  that 
the  evacuation  is  at  first  rapid.     When    the   pain  begins  be- 


Chronic  Duodenal  Ulcer  135 

tween  two  and  three  hours  after  a  meal,  only  a  small  proportion 
of  the  food  is  still  present  in  the  stomach,  the  hypertonic  con- 
dition constantly  present  in  cases  of  duodenal  ulcer  reaches  its 
greatest  development,  owing  to  the  increase  in  tone  which 
occurs  as  the  bulk  of  the  gastric  contents  diminishes.  Under 
these  conditions  peristaltic  contractions  can  produce  a  com- 
plete separation  of  the  pyloric  part  from  the  rest  of  the  stomach 
at  a  considerable  distance  from  the  pylorus.  Owing  to  the 
excessive  and  prolonged  secretion  of  normal  gastric  juice,  which 
is  the  cause  of  the  so-called  hyperchlorhydria  of  duodenal 
ulcer,  the  proportion  of  gastric  juice  and  of  hydrochloric  acid 
in  the  chyme  increases  as  digestion  proceeds.  At  the  first 
most  of  the  acid  combines  with  the  alkaline  salts  and  the  pro- 
teins of  the  food,  and  the  small  quantity  of  free  acid  which 
reaches  the  duodenum  is  rapidly. neutralised  by  the  alkaline 
intestinal  juice,  bile  and  pancreatic  juice,  so  that  the  relaxation 
of  the  pylorus  is  only  occasionally  inhibited.  But  after  two 
or  three  hours,  the  proportion  of  acid  present  being  greater, 
some  of  it  reaches  the  ulcer  before  it  is  neutralised.  The  in- 
hibition of  pyloric  relaxation,  which  the  contact  of  acid  with 
the  intact  duodenal  mucous  membrane  produces,  is  exagge- 
rated by  the  presence  of  the  ulcer,  so  that  the  peristaltic  waves 
advance  against  a  pylorus  which  only  opens  at  considerable 
intervals  in  order  to  permit  the  passage  of  a  small  quantity 
of  hyperacid  chyme  into  the  duodenum.  Immediate  relief 
to  the  pain  follows  the  administration  of  alkalies  or  proteins, 
which  neutralise  the  acid,  or  of  food  or  water,  which  dilutes 
it;  relief  is  also  produced  by  vomiting  and  lavage,  which  re- 
move the  acid  and  at  the  same  time  empty  the  stomach  so  that 
nothing  i-  left  upon  which  the  muscular  coat  can  contract. 
The  pain  disappears  spontaneously  only  when  tin'  stomach 
has  become  completely  empty." 


A.  ('.  Jordan  ("Brit.  Med.  Jour.,"  191 1,  i,  II72) 
has  also  investigated  a  series  of  cases  of  intestinal 
stasis  and  of  duodenal  ulcer  by  moan-  of  bismuth  meals 
and  .v-rays.     Ho   lays  greal    stress   niton  a   "duodenal 


136  Duodenal  Ulcer 

kink,"  a  kink  occurring  at  the  duodenojejunal  flexure, 
and  its  influence  in  causing  a  stagnation  of  the  contents 
in  the  duodenum.  He  and  Arbuthnot  Lane,  who  has 
inspired  his  enquiries,  speak  of  a  dilated  duodenum. 
And  dilatation  of  the  duodenum  is  referred  to  by  many 
writers,  and  is  considered  to  be  of  some  subtle  ill-under- 
stood character.  I  believe  that  too  much  is  made  of 
these  supposed  dilatations.  The  duodenum  is  a  mixing 
chamber  wherein  the  chyme  ejected  through  the  pylorus 
is  made  to  mingle  with  the  bile  and  the  pancreatic  juice. 
The  contractile  power  of  the  duodenum  is,  I  believe, 
small,  for  though  eager  waves  of  contraction  can  be 
seen  in  the  pyloric  part  of  the  stomach  and  in  all  parts 
of  the  jejunum  and  ileum,  they  are  extremely  rare  in 
the  duodenum.  The  duodenum  is  normally,  in  my 
experience,  both  large  and  inert.  Jordan  asserts  that 
he  has  demonstrated  a  kink  in  the  duodenum  producing 
an  obstruction  against  which  the  "powerful  contrac- 
tions of  the  duodenum"  worked  in  vain.  The  photo- 
graphs accompanying  his  article  do  not  carry  convic- 
tion to  my  mind.  It  is  further  said  to  be  necessary, 
in  order  that  this  condition  of  duodenal  stasis  may  be 
seen,  to  give  "a  full-sized  meal  containing,  as  a  rule, 
four  ounces  of  pure  bismuth  carbonate  in  the  form  of  a 
thick  emulsion."  My  conclusions  are  that  this  large 
dosage  explains  the  results  discovered,  and  that  the 
condition  described  is  normal  in  the  circumstances  in 
which  the  observations  were  made. 

Jordan  also  states  that  in  patients  suffering  from 
duodenal  ulcer  in  whom  pain  arises  two  or  three  hours 
after  a  meal  "the  pain  is  due  to  distension  of  the  duo- 


Chronic  Duodenal  Ulcer  137 

denum  resulting  from  obstruction."  This  statement, 
which  is  directly  opposed  to  all  clinical  experience,  is 
devoid  of  any  slightest  support  that  I  have  ever  been 
able  to  obtain. 

Dr.  A.  E.  Barclay,  of  Manchester,  who  has  devoted 
much  time  to  the  investigation  by  x-rays  of  the  condition 
of  the  alimentary  canal  after  the  ingestion  of  bismuth, 
writes:* 

"It  may  be  noted  in  this  condition  (duodenal  ulcer)  that 
just  beyond  the  pylorus  there  is  a  separate  shadow  which 
is  persistent,  and  it  is  quite  unaffected  by  the  peristalsis  of 
the  stomach;  therefore  the  shadow  is  in  the  duodenum.  In 
conjunction  with  this  we  usually  have  the  picture  of  a  per- 
fectly healthy  stomach  in  which  peristalsis  is  more  violent 
than  usual,  and  a  feature  I  have  noticed  in  main  cases  is 
that  the  gastric  contents  are  passed  on  more  rapidly  than 
usual,  so  that  the  stomach  is  sometimes  empty  in  as  short  a 
time  as  half  an  hour.  This  rapid  emptying  of  the  stomach  may 
account  for  the  hunger  pain,  on  which  so  much  has  been 
written  lately. 

"The  picture  of  a  normal  stomach  exhibiting  excessive 
peristalsis  and  passing  the  food  on  very  rapidly  is  very  sug- 
gestive, if  not  diagnostic,  of  trouble  in  or  about  the  duodenum ; 
but  the  presence  of  a  separate  bolus  in  the  duodenum  i> 
accidental,  and  depends  upon  the  presence  of  cicatrices  or 
spasmodic  conditions  causing  pockets  in  the  inferior  surface. 
The  whole  picture  is  very  suggestive,  but  it  is  not  diagnostic 
of  duodenal  ulcer,  since  it  may  be  due  to  puckering  of  the 
duodenum    from   other  causes,   Mich   as   carcinoma." 

The  diagnosis  of  duodenal  ulcer,  therefore,  depends 
upon — 

First  and  foremost  (indeed,  almost  exclusively),  the 
anamnesis.     The    history,    sel     forth    in    detail    above, 

*".\|-(lir  K.r     "     [9IO,     [23. 


138  Duodenal  Ulcer 

enables  a  diagnosis  to  be  made  with  a  very  small  risk 
of  error. 

Second,  the  discovery,  during  the  stage  of  active 
ulceration,  during  "the  attacks,"  that  is,  of  an  increased 
secretion  of  free  HC1. 

Third,  the  characteristic  picture  given  upon  .r-ray 
examination  after  a  bismuth  meal.  The  stomach  has 
an  enhanced  activity  in  respect  both  of  its  secretory 
and  of  its  motor  functions. 

Fourth,  the  discovery  of  occult  blood  in  the  faeces 
during  the  stage  of  active  ulceration  if  daily  exami- 
nations of  the  faeces  are  made.  In  the  later  stages,  of 
course,  the  appearances  due  to  slight  or  severe  stenosis 
may  be  presented. 


CHAPTER  VII 
DIFFERENTIAL  DIAGNOSIS 

The  chief  difficulties  likely  to  be  encountered  in 
making  an  accurate  diagnosis  of  duodenal  ulcer  are 
concerned  with  the  discrimination  of  this  condition 
from  cholelithiasis  and  from,  gastric  ulcer.  In  a  con- 
secutive series  of  ioo  operations  wherein  I  had  made  a 
written  diagnosis  of  duodenal  ulcer  an  error  was  com- 
mitted in  three  cases.  In  two  of  them  gall-stone  disease 
was  present,  and  in  the  third,  gall-stones  and  appendicitis. 
In  earlier  cases  I  had  made  the  diagnosis  incorrectly 
more  often  than  this,  confusing  gastric  ulcer  with  an 
ulcer  beyond  the  pylorus,  but  in  nearly  all  cases  an 
organic  lesion  was  found  to  be  present.  The  earlier 
errors  were  made  in  cases  of  gastric  ulcer,  cholelithiasis, 
and  appendicitis,  either  simple  or  tuberculous,  and  in 
cases  in  which  no  structural  disease  could  be  found. 

In  the  differentiation  from  gastric  ulcer  there  is,  as 
a  rule,  no  great  difficulty.  If  pain  after  food  doe-  not 
appear  for  two  hours  or  more,  it  may  be  said  with  reason- 
able confidence  thai  the  ulcer  is  in  the  duodenum.  I 
.mi  convinced  of  the  importance  of  tlie  time-element  in 
case-  of  gastric  and  duodenal  ulcer,  and  for  many  years 
have  emphasised  it-  significance.  If  pain  appear-  early 
,ift<r  an  ordinary  meal,     within  an  hour  or  so,     the  ulcer 

[39 


140  Duodenal  Ulcer 

is  certainly  in  the  stomach,  probably  on  the  lesser 
curvature.  If  pain  comes  between  one  and  two  hours 
after  food,  the  ulcer  is  probably  in  the  pyloric  antrum. 
The  period  of  relief  from  pain  conferred  by  the  taking 
of  a  meal  is  then  the  first  and  chief  point  to  be  con- 
sidered in  the  differential  diagnosis. 

Dr.  Hertz  ("The  Sensibility  of  the  Alimentary 
Canal,"  191 1,  p.  58)  offers  the  following  explanation 
of  the  time  relation  between  the  taking  of  food  and  the 
onset  of  pain  in  cases  of  gastric  and  duodenal  ulcer: 

"The  time  relations  can  be  explained  by  considering  at 
what  moment  free  hydrochloric  acid  comes  into  contact  with 
the  ulcer  so  as  to  lead  to  an  exaggeration  of  the  reflex  motor 
efforts  which  produce  pain.  The  hydrochloric  acid  is  secreted 
mainly  by  the  glands  of  the  proximal  two-thirds  of  the  stomach, 
the  secretion  of  the  extreme  pyloric  end  being  actually  alkaline. 
As  no  peristalsis,  consequently  no  churning  of  the  contents, 
occurs  in  the  fundus,  the  outer  layer  of  chyme  remains  con- 
stantly very  acid.  A  cardiac  ulcer  is,  therefore,  bathed  in  acid 
gastric  juice  at  a  very  early  stage  in  digestion.  The  food  which 
first  reaches  the  pyloric  end  of  the  stomach  is  alkaline;  it  is 
cnly  after  a  considerable  interval  that  the  acid  gastric  juice 
reaches  this  part  to  any  great  extent,  and,  as  peristalsis  is 
constantly  active  in  the  pyloric  part,  the  gastric  juice  is  greatly 
diluted  by  the  large  quantity  of  food  with  which  it  is  mixed. 
Consequently,  an  hour  or  more  may  pass  before  there  is  suffi- 
cient free  acid  to  irritate  an  ulcer  near  the  pylorus.  The 
intermediate  portion  of  the  stomach  differs  from  the  pyloric 
end  in  secreting  an  acid  juice;  this  does  not,  however,  remain 
in  contact  with  the  mucous  membrane  in  a  concentrated  state 
as  it  does  in  the  cardiac  end,  for  it  is  constantly  mixed  by 
peristalsis  with  the  alkaline  food.  Consequently,  an  ulcer  in 
this  situation  is  irritated  by  acid  at  an  interval  after  a  meal 
intermediate  between  that  which  elapses  in  cardiac  and  in 
pyloric  ulcers." 


Differential  Diagnosis  141 

The  striking  recurrence  of  a  duodenal  ulcer  at  various 
seasons  of  the  year  is  not  shared  by  gastric  ulcer.  One 
of  the  most  authentic  features  in  duodenal  ulcer  is  this 
recurrence  of  attacks  in  the  cold  and  wet  seasons.  One 
patient  after  another  will  tell  of  the  influence  of  the  cold 
weather,  or  of  a  chill,  upon  the  natural  history  of  his 
disorder;  some  of  these  patients  complain  constantly 
of  cold  hands  and  cold  feet;  but  the  blood  pressure  in 
many  of  the  cases  is  certainly  high.  In  gastric  ulcer 
there  does  not  seem  to  be  the  same  dependence  of  the 
attacks  upon  the  climate  or  the  seasons. 

In  gastric  ulcer  pain  is  always  referred  to  the  middle 
line,  and  it  usually  is  so  in  duodenal  cases,  though  not 
always.  The  painful  area  is,  I  think,  a  little  higher 
in  the  middle  line  in  gastric  than  in  duodenal  ulceration. 
I  n  cases  of  duodenal  ulcer  there  is  not  seldom  a  chief  com- 
plaint of  pain  on  the  right  side,  radiating  over  the 
right  costal  margin  up  towards  the  breast,  or  round  to 
the  back.  Tenderness  on  deep  pressure,  if  present,  is 
always  to  the  right.  If  the  ulcer  has  attached  itself  to 
the  liver  or  to  the  anterior  abdominal  wall,  these  radiat- 
ing pains,  and  the  area  of  tenderness,  are  undoubtedly 
more  marked. 

In  gastric  ulcer  the  radiation  is  often  to  the  left  costal 
margin  and  to  the  left  breast,  and  even  at  times  may  be 
fell  down  the  arm.  Tenderness  on  deep  pressure  be- 
neath the  left  costal  margin  when  a  deep  inspiration 
is  taken  is  often  found  when  an  ulcer  is  presenl  on  the 
lesser  curvature  towards  the  cardia.  Tain  in  the  back 
is  a  constant  feature  in  those  cases  of  gastric  ulcer  in 
which  the  pancreas  i>  deeply  eroded.      It  is  analogous 


142  Duodenal  Ulcer 

to  that  severe  pain  which  is  a  striking  feature  in  cases 
of  acute  pancreatitis. 

So  far  as  the  preventable  complications  of  ulcer  are 
concerned,  it  is  undoubtedly  the  case  that  haematemesis 
in  the  absence  of,  or  in  marked  excess  of,  melsena  is 
found  only  in  gastric  ulcer.  Both  haematemesis  and 
melaena  may  be  present  in  cases  of  duodenal  ulcer,  but 
the  latter  is  more  frequent  and  is  in  excess  of  the  former. 

In  a  case  operated  upon  in  19 10  I  had  made  a  diag- 
nosis of  duodenal  ulcer  after  eliciting  what  I  felt  sure 
was  an  authentic  history  of  duodenal  ulcer.  At  the 
operation  no  ulcer  was  discoverable  in  the  duodenum. 
In  the  stomach,  on  the  posterior  wall,  nearer  the  cardia 
than  the  pylorus,  was  an  ulcer,  almost  circular  and  two 
inches  in  diameter,  deeply  eroding  the  pancreas.  The 
base  of  the  ulcer  was  formed  by  the  pancreas,  the  stomach 
wall  having  been  thoroughly  destroyed.  Even  after 
the  recovery  of  the  patient  from  the  operation  (excision 
of  the  ulcer,  etc.)  the  only  discrepancies  between  the 
story  given  by  him  and  the  typical  history,  as  I  have 
related  it,  were  that  the  seasonal  variations  had  never 
been  observed,  that  pain  in  the  back  had  been  unre- 
mitting, and  that  the  symptoms  had  been  present  with- 
out intermission  for  over  three  years.  Cases  similar 
to  this  one  are  sparsely  recorded,  but  two  almost  iden- 
tical instances  have  been  mentioned  to  me  in  conver- 
sation by  surgeons  well  versed  in  these  matters.  Mr. 
Caird  ("Edin.  Med.  Jour.,"  191 1,  319)  records  the 
following  case  as  illustrating  the  mimicry  of  some  of 
the  symptoms  of  duodenal  ulcer  by  a  malignant  growth 
in  the  stomach : 


Differential  Diagnosis  143 

Mrs.  X.,  aged  forty-five,  developed  gastric  symptoms  in 
summer,  1909.  Epigastric  pain,  of  a  dull,  gnawing  character, 
came  on  two  and  a  half  to  three  hours  after  meals,  and  was  in- 
variably relieved  by  taking  more  food.  This  pain  has  persisted 
for  the  last  eighteen  months  with  varying  severity,  and  latterly 
she  has  been  able  to  control  it  by  taking  sod.  bicarbonate 
and  Gregory's  powder.  She  has  been  greatly  troubled  by 
nocturnal  pain,  and  has  been  in  the  habit  of  taking  some  form 
of  nourishment,  e.  g.,  soup,  at  2  a.  m..  and  she  frequently  eats 
biscuits  in  the  morning  about  one  hour  before  breakfast  to 
stave  off  the  epigastric  pain.  There  has  been  no  vomiting. 
She  is  fairly  well  nourished,  but  has  lost  much  weight. 

From  a  general  consideration  of  this  case  and  the  fact  that 
no  epigastric  resistance  was  palpable,  and  that  the  test-meal 
contained  no  free  HC1,  the  correct  diagnosis  of  carcinoma  was 
made.  The  disease  involved  the  lesser  curvature  and  pyloric 
antrum  and  was  at  least  one  inch  remote  from  the  pylorus. 


In  such  a  case  as  this  the  correct  diagnosis  is  not 
difficult.  The  patient  was  a  woman  over  forty  years 
of  age;  this  was  her  first  attack  of  gastric  disorder; 
the  symptoms  suffered  no  abatement  from  their  onset; 
there  were  none  of  the  remissions  and  exacerbations,  the 
seasonal  variations,  which  are  so  characteristic  of  duo- 
denal ulceration;  there  was  no  free  HC1  in  the  stomach 
contents,  and  there  was  much  loss  of  weight.  The 
case  illustrates  very  well  the  point  upon  which  1  have 
frequently  insisted;  namely,  that  exclusive  reliance  is 
not  to  be  placed  upon  one  symptom  alone,  but  thai  an 
opinion,  to  be  sound,  must  be  based  upon  all  the  details 
elieited  in  .1  close  examination  of  the  anamnesis. 

The  following  similar  case  occurred  in  my  own  prac- 
tice. The  patienl  was  .1  medical  man,  aged  fifty,  who 
wrote  the  following  account  of  his  own  case: 


144  Duodenal  Ulcer 

Had  enteric  twenty-seven  years  ago;  in  third  week  sudden 
severe  pain  in  right  iliac  region,  which  persisted  for  some  hours. 
After  recovery  had  occasional  attacks  of  pain  which  were  at- 
tributed to  "adhesions."  At  times  during  the  intervening 
years  had  pain  and  feeling  of  fullness  in  right  iliac  region. 
During  last  three  or  four  years  subject  to  pain  in  right  hypo- 
chondrium  and  infrascapular  regions  which  was  thought  to 
be  "  muscular."  These  pains  became  more  pronounced  during 
the  autumn  of  1910  under  unusual  stress  of  wrork,  irregular 
meals,  and  the  exertion  of  starting  motor  engine,  until  one  day 
late  in  November,  after  a  hearty  meal,  severe  pain  occurred  in 
the  epigastrium  and  followed  subsequent  meals.  It  was  so 
severe  that  I  abstained  from  all  food  except  light  puddings  and 
milk.  After  two  or  three  weeks  the  pain  localised  itself  to  the 
right  hypochondrium,  especially  at  the  costal  margin,  where 
pressure  was  painful,  with  a  dull  aching  sensation  at  times  in 
the  infrascapular  region.  At  this  time  bicarbonate  of  soda 
taken  when  the  pain  commenced  gave  some  relief.  About  the 
end  of  December  I  saw  a  physician,  who  agreed  that  the  symp- 
toms were  due  to  duodenal  ulcer.  Had  rest  in  bed  for  three 
weeks  and  began  to  take  more  food  but  at  frequent  intervals 
to  appease  feeling  of  hunger.  The  rest  did  good  in  every  way, 
but,  on  resuming  work,  the  fixed  pain  at  the  costal  margin 
became  more  marked  again.  It  was  sometimes  relieved  by 
taking  food  but  often  persisted.  Since  January,  191 1,  this 
pain  and  the  dull  aching  in  the  infrascapular  region  have 
alternated  with  a  much  more  acute  pain  in  the  right  hypo- 
chondrium, which  came  on  at  variable  intervals  after  meals — 
at  first  about  three  hours,  then  two  and  a  half,  and  latterly 
two.  At  times  nothing  seemed  to  give  relief,  the  pain  gradu- 
ally diminishing.  At  other  times  food,  alkalies,  or  olive  oil 
relieved.  Towards  the  end  of  August  the  pain  became  very 
marked  during  the  night,  wraking  me  from  sleep  and  persisting 
for  an  hour  or  two.  At  that  time  and  at  present  (Sept.)  it  is 
chiefly  an  acute  nipping  sensation  below7  the  right  costal 
margin  which  occurs  regularly  about  two  and  a  half  hours  or 
two  hours  alter  food  with  local  tenderness.  No  haemorrhage 
has  been  detected  and  there  has  been  no  vomiting  unless  ac- 
companying migraine.     There  has  been   no  vomiting  at  all 


Differential  Diagnosis  145 

since  November,  1910,  and  migraine,  when  present,  has  been 
less  severe  than  formerly.  The  bowels  have  been  fairly  regular, 
but  easily  thrown  wrong  if  anything  interfered  with  routine 
attention.  Latterly,  relief  afforded  by  alkalies  has  been  less 
marked  than  during  the  earlier  stages  of  the  illness.  During 
the  last  nine  months,  21  pounds  in  weight  has  been  gained,  and 
now  I  am  heavier  than  ever  before.  This  is  due  to  the  fact 
that  I  am  eating  more,  or  more  frequently,  than  I  am  accus- 
tomed to  do. 

At  the  operation  a  large  ulcer  was  found  close  to 
the  pylorus,  deeply  excavating  the  pancreas.  From 
it  a  hard,  gritty  extension  passed  upwards  to  the  lesser 
curvature,  along  which  all  the  glands  were  enlarged; 
and  along  the  greater  curvature  almost  to  the  oesophagus 
a  broad,  tape-like  strand  of  growth  extended.  The 
anterior  and  posterior  walls  of  the  stomach  were  both 
stiff  with  an  infiltrating  growth.  In  this  case  also, 
though  a  spurious  hunger  pain  was  present,  many  of 
the  characteristic  symptoms  of  duodenal  ulcer  were 
lacking. 

There  are  a  number  of  cases  recorded  in  the  litera- 
ture, and  several  were  mentioned  in  the  discussion  held 
upon  "duodenal  ulcer"  at  the  Royal  Society  of  Medi- 
cine in  London  ("Trans.  Roy.  Soc.  Med.,"  1910,  iii, 
304)  wherein,  among  other  things,  the  patient  com- 
plained of  pain  one  or  more  hours  after  food.  On 
exploration,  or  at  the  autopsy,  no  lesion,  or  a  lesion 
in  parts  other  than  the  duodenum,  was  found.  The 
inference  wa>.  therefore,  drawn  that  "hunger  pain" 
was  not  pathognomonic  of  duodenal  ulcer.  So  tar  as 
I  know  no  one  has  ever  asserted  th.it  it  is.  When  I 
first   introduced    the  expression   "hunger  pain"  and   in 


146  Duodenal  Ulcer 

all  that  I  have  written  since,  I  have  used  this  term  in 
a  very  strict  and  specific  sense.  One  of  the  difficulties 
confronting  an  author  to-day  is  the  desire  of  many 
readers  for  the  most  concentrated  epitome  of  his  message. 
The  torrent  of  Niagara  must  be  described  in  terms  of 
the  pipette.  So  this  term  "hunger  pain,"  debased 
and  shorn  of  all  the  authentic  attributes  with  which  I 
had  clothed  it,  is  held  to  indicate  the  presence  of  an 
ulcer  in  the  duodenum.  I  must  insist,  however,  that 
all  the  varied  qualities  of  this  important  symptom  re- 
quire consideration  before  a  diagnosis  based  upon  it  can 
have  substantial  value.  The  term,  in  the  full  sense 
which  I  give  to  it,  and  in  that  sense  only,  is  strongly 
indicative  of  the  existence  of  duodenal  ulceration. 

The  chief  difficulty  in  diagnosis  is  met  with  in  chole- 
lithiasis; but  here  also  a  close  scrutiny  and  analysis  of 
the  symptoms  should  enable  a  correct  forecast  to  be 
made  in  almost  every  instance.  Above  all  in  importance 
is  the  orderly  sequence  of  events.  There  is  method  in 
the  natural  history  of  duodenal  ulcer;  there  are  the 
definite  attacks,  attributable  to  well-recognised  causes, 
appearing  at  certain  seasons,  eased  by  diet,  instantly 
relieved  by  alkalis  or  by  lavage,  to  be  followed  presently 
by  the  complete  abeyance  of  all  symptoms.  Such  a 
definite  periodicity  is  never  seen  in  gall-stone  disease. 
The  character  of  the  pain  in  the  two  differs  essentially. 
In  the  very  great  majority  of  cases  of  duodenal  ulcer  the 
pain,  though  it  may  be  severe,  is  tolerable;  in  chole- 
lithiasis it  often  is  almost  unendurable.  I  have  known 
medical  men  who  suffered  from  gall-stones  to  carry  with 
them  a  small  bottle  of  chloroform,  so  that  if  an  attack  of 


Differential  Diagnosis  147 

pain  came  they  could  inhale  the  vapour  and  get  relief. 
Though  I  have  operated  upon  many  medical  men  with 
duodenal  ulcers,  I  have  never  known  one  to  look  upon 
the  pain  as  so  terrifying  a  thing  as  to  call  for  this.  More- 
over, in  hepatic  colic  the  onset  of  pain  is  usually  within 
an  hour  of  the  taking  of  food.  The  pain  begins  suddenly, 
as  a  feeling  of  acute  distension,  and  it  is  only  after  a 
while  that  the  feeling  of  cramp  develops.  In  an  attack 
of  hepatic  colic,  there  is  often  a  "catch  in  the  breath,"  a 
most  characteristic  symptom,  and  a  feeling  of  great 
depression  .  and  nausea  is  accompanied  by  sweating. 
Acidity,  or  heartburn,  is  not  infrequently  present  in 
cholelithiasis.  The  pain,  as  I  have  said,  begins  suddenly, 
and  almost  instantly  it  may  pass  away.  It  is  abrupt, 
in  both  onset  and  relief,  and  in  both  it  differs  from  the 
pain  of  duodenal  ulcer.  Food  or  an  alkali  has  no 
influence  in  relieving  the  pain  of  gall-stones,  and  the 
idea  of  even  the  smallest  quantity  of  nourishment  is 
repugnant.  I  believe  a  frequent  and  important  feature 
of  cholelithiasis  to  be  the  experiencing  of  chills  and 
sweats;  a  feeling  of  "gooseflesh,"  shivering,  and  sub- 
sequent heat  are  often  mentioned  in  the  anamnesis. 
The  sensation  of  pain  felt  in  the  shoulder-blade  is  very 
suggestive  of  gall-stone  impaction  in  the  cystic  duct. 
As  Dr.  J.  B.  Murphy  has  shewn,  the  introduction  <>t  .t 
probe  into  the  cystic  duct  through  a  cholecystotomy 
opening  is  at  once  recognised  by  the  patient,  who  refers 
the  pain  to  the  right  shoulder-blade.  So  definite  a 
localisation  is  not  known  in  duodenal  ulcer. 

In  cholelithiasis,  in  its  more  advanced  form,  the  pain 
is  capricious  in  onset,  comes  upon  the  patient  unawares, 


148  Duodenal  Ulcer 

and  grips  him  instantly  in  such  manner  as  to  compel  him 
to  cease  from  all  other  things  than  the  means  of  getting 
relief.  The  pain  is  cramp-like,  and  a  feeling  of  insuffer- 
able distension  in  the  epigastrium  is  present.  The  pain 
extends  across  the  abdomen  in  its  upper  part,  and  passes 
through,  or  round,  the  side  to  the  shoulder-blade. 
There  is  a  sharp  catch  in  the  breath  and  a  feeling  of 
chilliness  and  fever.  The  attack  may  be  of  such  severity 
that  chloroform  or  morphine  is  needed  to  obtain  relief. 
Nausea,  retching,  and  vomiting  prostrate  the  patient, 
and  then  ease  may  come.  Freedom  from  pain  is  often 
instant,  only  a  feeling  of  stiffness  or  soreness  remains 
for  some  hours.  There  is  no  approach  to  the  regular, 
orderly  sequence  of  events  that  is  so  strongly  suggestive 
of  ulcer  of  the  duodenum.  The  complications  of  duo- 
denal ulcer,  hsematemesis,  and  melsena  are  not  seen  in 
cases  of  cholelithiasis  in  which  a  difficulty  of  diagnosis 
is  likely  to  arise. 

There  are,  as  every  surgeon  knows,  a  number  of  cases 
of  cholelithiasis  in  which,  when  an  operation  is  per- 
formed, adhesions  between  the  gall-bladder,  on  the  one 
hand,  and  the  stomach  and  duodenum,  on  the  other,  are 
found.  These  adhesions  are  of  every  variety  of  intimacy : 
occasionally,  only  a  fine  web  of  tissue  is  found;  occa- 
sionally, the  gall-bladder  may  communicate  with  the 
cavity  of  the  duodenum  through  a  small  fistula;  or  the 
gall-bladder  may  be  almost  inextricably  attached  to 
the  pylorus  or  to  the  duodenum.  In  one  patient  I 
found  a  gall-stone  the  size  of  a  billiard  chalk  King  almost 
entirely  within  the  lumen  of  the  duodenum.  In  cases 
such   as   these   a   varying   degree   of   chronic   dyspepsia 


Differential  Diagnosis  149 

may  be  present,  with  stasis  of  the  stomach  contents; 
and  well-marked  peristaltic  waves  may  be  seen  when 
the  stomach  is  inflated.  The  difficulties  in  diagnosis 
may  be  increased  by  the  discovery  of  an  excess  of  acid 
in  the  gastric  juice,  for  this,  as  Ewald  shewed  long  ago, 
is  found  from  time  to  time  in  cases  of  cholelithiasis. 
I  am,  nevertheless,  convinced  that  with  a  close  scrutiny 
of  all  the  details  of  the  clinical  history  an  accurate 
diagnosis  is  possible  in  the  very  great  majority  of  cases. 
There  are  cases,  extremely  few  in  number,  I  believe, 
wherein  a  mimicry  of  the  symptoms  of  duodenal  ulcer 
is  found,  in  the  absence,  upon  exploration,  of  any  definite 
organic  lesion.  It  is  true  that  one  hears  of  such  cases 
not  very  infrequently,  but,  in  almost  all  no  adequate 
examination  of  other  parts  has  been  made.  I  have,  for 
example,  known  gastroenterostomy  to  be  performed 
after  a  diagnosis  of  duodenal  ulcer  had  been  made.  The 
symptoms  were  of  a  kind  to  make  such  a  diagnosis  reason- 
ably probable.  The  patient  died;  at  the  autopsy  a 
gall-bladder  full  of  stones  was  discovered  and  no  other 
lesion  of  any  kind.  I  believe  it  to  be  true  that  in  most 
cases  where,  at  the  time  of  operation,  a  duodenal  (or 
gastric)  ulcer  cannot  be  found,  some  other  lesion,  in 
the  gall-bladder,  small  intestine,  or  appendix,  is  present, 
and  is  overlooked.  In  a  very  small  number,  however, 
an  organic  lesion  may,  in  fact,  be  absent.  Such  cases 
require  further  investigation.  All  that  I  am  prepared 
to  say  with  regard  to  them  now  is  thai  as  my  experience 
has  increased  the  number  of  those  cases  has  decreased 
to  the  vanishing  point.  Too  strong  emphasis  cannol 
be  laid,  however,  upon   this:    thai   in  the  absence  ol  a 


150  Duodenal  Ulcer 

demonstrable  lesion  the  operation  of  gastro-enterostomy 
is  not  justifiable.  It  will  give  no  relief  and  disaster  will 
often  follow  fast  upon  it. 

One  of  the  conditions  which  must  constantly  be  borne 
in  mind  by  those  who  are  called  upon  to  investigate  the 
protean  forms  of  gastric  disorder  is  locomotor  ataxy. 
I  find  that  in  the  last  few  years  I  have  had  seven  cases 
of  tabes  dorsalis  and  three  cases  of  lead  poisoning 
sent  to  me  in  the  expectation  that  I  should  suggest 
surgical  treatment  for  the  gastric  disablement  which 
was  present  in  every  case.  There  is,  as  a  rule,  no  diffi- 
culty in  distinguishing  the  crises  of  locomotor  ataxy 
from  the  "attacks"  of  duodenal  ulcer,  if  attention  be 
paid  to  the  ocular  symptoms,  the  history  of  lightning 
pains,  and  the  absence  of  knee-jerks.  But  I  have  met 
with  one  case  which  perplexed  me  very  much;  of  its 
true  explanation  I  am  not  yet  convinced.     (Case  273.) 

The  symptoms  in  this  case  were,  I  believe,  due  in 
part  to  the  narrowing  of  the  pylorus  by  an  almost 
annular  pancreas  which  had  probably  undergone  a 
specific  inflammatory  change  leading  to  sclerosis,  and 
in  part  to  tabes  dorsalis.  On  dissecting  away  the 
pancreas  from  the  duodenum  the  mucosa  was  wounded, 
and  the  bowel  opened.  The  closure  of  this  wound  in 
the  gut  added  so  much  to  the  stenosis  that  gastro- 
enterostomy was  necessary.  The  patient  was  suffering 
from  early  tabes,  there  were  no  knee-  or  ankle- jerks  on 
either  side,  the  pupils  were  small,  unequal,  and  did  not 
react  to  light,  and  there  were  occasional  shooting  pains 
in  the  limbs,  especially  on  fatigue  (the  man  was  a  rail- 
way guard  J.     Since   the    operation  the  patient  has   re- 


Differential  Diagnosis  151 

gained  his  lost  weight  and  returned  to  light  work,  though 
the  tabetic  condition  makes  steady  progress.* 

In  some  cases  the  condition  of  "appendix  dyspepsia" 
"Brit.  Med.  Jour.,"  1910,  Jan.  19th)  will  give  rise  to 
symptoms  that  are  with  difficulty  to  be  distinguished 
from  those  of  duodenal  ulcer  or  of  gastric  ulcer.  What 
are  the  symptoms  of  the  dyspepsia  due  to  chronic 
appendicitis?  The  chief  of  them,  of  course,  is  pain,  or 
in  many  cases  a  continuing,  wearying  discomfort  rather 
than  an  acute  pain.  This  feeling  comes  always  after 
food,  and  is  attributed  to  the  meal  which  has  been 
taken;  it  is  spoken  of  as  "indigestion."  It  is  almost 
always  confined  to  the  epigastrium,  £>r  is  worse  there  if 
radiation  to  one  or  other  side  of  the  lower  part  of  the 
abdomen  is  felt.  Pressure  in  the  right  iliac  fossa  will 
often  cause  the  same  sensation  of  pain  or  discomfort 
in  the  epigastrium  as  follows,  usually,  upon  taking  of 
a  meal.  The  time  of  the  onset  after  food  is  very  vari- 
able; it  may  be  a  few  moments,  it  may  be  one  hour  or 
two,  or  even  more.  Some  articles  of  diet  produce 
more  severe  and  earlier  discomfort  than  others;  in 
some  patients  red  meat  is  not  to  be  taken  without 
<li~a>ter;  in  others  starchy  foods  are  banished  from  the 
table.  A  friend  of  mine,  a  medical  man,  whose  appen- 
dix I  removed  tor  inveterate  dyspepsia,  told  me  that  he 
could  almost  indicate  the  percentage  of  starch  present 
in   any    food    by    the   discomfort    which    it    produced;     if 

*  I  am  disposed  to  think  that ,  in  t  he  few  cases  in  which  I  have  prrformed 

.  when  the  patienl  In-  been  suffering  from  the  gastric 

crises  "i   tabes  > l< >r^.il i^  (the  medical  diagnosis  <>i   "gastric  ulcer"  being 

unsupported  by  the  disclosures  upon  the  operation  table),  the  relief  to 

the  patient  has  been  considerable. 


152  Duodenal  Ulcer 

a  large  quantity  were  present  he  produced  "wind 
enough  to  drive  a  wind-mill."  Flatulence,  fullness  and 
acid  sour  belchings  are  common,  and  a  feeling  of  intes- 
tinal unrest  may  not  seldom  be  present.  Vomiting  is 
often  seen,  indeed,  it  is,  I  think,  the  most  troublesome 
symptom,  though  it  is  the  one  conspicuous  means  by 
which  relief  from  pain  and  over- fullness  is  obtained. 
The  vomiting  comes  sometimes  within  a  few  minutes 
or  half  an  hour  of  the  meal,  and  almost  unaltered  food 
may  be  returned.  In  not  a  few  cases  haematemesis  or 
melsena  may  be  present,  and  may  even  be  profuse. 

The  symptoms  which  I  have  so  briefly  outlined  are 
not  dissimilar  from  those  to  which  a  diagnosis  of  "gas- 
tric ulcer"  would  be  attached  by  many  physicians. 
There  are,  however,  certain  points  of  sharp  distinction 
as  well  as  of  close  resemblance.  In  cases  of  chronic 
duodenal  ulcer,  and  to  a  lesser  degree  of  gastric  ulcer, 
for  example,  there  are  very  remarkable  periods  of  remis- 
sion; in  these  the  patients  suffer  little  or  not  at  all  in 
the  intervals  between  severe  and  disabling  attacks; 
in  "appendix  dyspepsia"  even  brief  intervals  of  repose 
are  rare.  As  a  rule,  symptoms  are  present  with  little 
or  no  remission  for  years,  though  from  time  to  time 
there  may  be  an  exacerbation  in  which  discomfort 
develops  into  pain,  even  of  a  Aery  acute  character. 
In  cases  of  duodenal  or  gastric  ulcer,  relief  from  the 
symptoms  will  often  follow  a  brief  rest  from  work  and 
its  attendant  anxieties;  a  week-end  by  the  sea  in  summer 
will  be  followed  by  a  period  of  relief;  in  cases  of  "appen- 
dix dyspepsia"   there  is  little  alteration  in  the  warmer 


Differential  Diagnosis 


:>:> 


months  of  the  year,  and  exercise  almost  without  excep- 
tion makes  the  pain  worse. 

In  cases  of  "appendix  dyspepsia"  there  is,  as  Paterson 
has  well  shewn,  a  hypersecretion  of  the  gastric  juice. 
After  the  appendix  has  been  removed,  the  secretion 
of  gastric  juice  returns  to  the  normal  amount  ("Trans. 
Roy.  Soc.  Med.,"  1910,  iii,  6,  pages  198  and  199). 

The  best  case  of  mimicry  of  the  symptoms  of  a  duo- 
denal ulcer  by  a  diseased  appendix  is  recorded  by 
Mitchell  ("Trans,  lister  Med.  Soc,"  1910-1911,  re- 
print pages  6  and  7) : 

"A  young  married  lady,  aged  twenty-nine,  visited  me  on  the 
28th  of  February,  19 10,  accompanied  by  her  husband.  She  in- 
formed me  she  had  come  to  arrange  for  an  operation  for  duo- 
denal ulcer.  She  had  seen  several  medical  men,  had  tried 
milk  diet  and  rest  in  bed,  without  benefit.  Her  daily  history 
with  slight  variations  was  as  follows:  Quite  comfortable 
when  she  got  up  in  the  morning;  breakfast  9  o'clock,  pain 
coming  on  about  11.30  to  12  o'clock,  and  getting  worse  till 
dinner  at  I  o'clock.  This  meal  at  once  gave  relief,  and  she 
was  quite  comfortable  till  between  3  o'clock  p.  m.  and  5  o'clock 
p,  \i.,  the  interval  depending  on  the  nature  of  her  dinner.  Once 
the  pain  began  it  steadily  got  worse,  so  thai  if  she  happened  to 
be  down  town  shopping  she  was  obliged  to  have  afternoon 
tea,  the  result  oi  which  was  prompt  relief.  She  look  her 
ordinary  tea  about  6.30,  after  which  she  generallj  remained 
well,  but  occasionally  the  pain  came  back  aboul  8  o'clock.  It, 
however,  never  came  on  after  she  went  to  bed  or  wakened  her 
,1!  night.  She  had  slight  tenderness  over  the  right  rectus  at 
the  level  ol  the  umbilicus.  This  being  below  the  usual  site,  I 
enquired  whether  she  ever  had  an  attack  of  appendicitis,  bul 
she  could  recollect  nothing  of  the  kind.  At  operation,  6th  of 
March,  [910,  her  family  medical  attendant  being  present,  we 

found  a  healthy  stomach  and  duodenum.      The  appendix  u.i^ 

4'._;  inches  long.     At   a  point    1   inch  from  the  caecum  il  was 


154  Duodenal  Ulcer 

tightly  constricted,  the  remaining  3V0  inches  was  distended  to 

the  thickness  of  an  index  finger,  and  the  tip  was  fixed  by  ad- 
hesions. The  appendix  was  removed.  She  made  rapid  re- 
covery, and  her  medical  attendant  informs  me  she  has  re- 
mained well  since  the  operation. 

"This  history  at  first  sight  appeared  quite  typical.  The 
absence  of  night  pain  and  the  position  of  such  tenderness  as 
appeared  to  be  present  suggested  the  possibility  of  an  ap- 
pendical  origin.  Our  incision  was  therefore  made  through  the 
right  rectus  opposite  the  umbilicus,  so  that  it  could  be  extended 
up  or  down  as  required." 

There  can,  I  think,  no  longer  be  any  question  that 
both  gastric  and  duodenal  ulcers  are  secondary  to  some 
toxic  or  infective  process,  the  various  stages  of  the 
disorder  being  infection,  congestion  of  gastric  mucosa, 
with  erosion  (possibly  the  result  in  many  cases  of  retro- 
grade venous  embolism,  as  shewn  by  Wilkie  in  "Edin. 
Med.  Jour.,"  191 1,  i),  superficial  ulceration  (the 
"medical  ulcer"  of  American  authors),  and  finally 
chronic  ulcer.  In  many  of  my  cases  the  primary  septic 
focus  would  certainly  appear  to  have  been  in  the  appen- 
dix. It  is,  therefore,  probable  that,  in  some  instances 
in  which  symptoms  suggestive  of  duodenal  ulceration 
have  been  present  and  only  a  diseased  appendix  dis- 
covered, some  superficial  and  inconspicuous  lesion  of 
the  duodenal  mucosa  was  already  established.  This 
view  is  borne  out  by  a  case  in  my  own  series  and  by 
the  following  interesting  case  reported  by  Paterson 
("Lancet,"   191 1,  i,  97): 

"The  patient  was  a  lady  forty-two  years  of  age,  sent  to  me 
by  Dr.  Stanlev  L.  Box.  Sixteen  years  before  I  saw  her  she 
had  peritonitis,  and  was  ill  for  months.     A  year  later  she  had 


Differential  Diagnosis 


33 


'ulceration  of  the  bowels.'  Two  years  after  that  she  began 
to  suffer  from  gastritis,  and  a  few  years  later  she  had  ha^mat- 
emesis.  In  January,  1909.  she  was  taken  ill  suddenly,  with 
violent  vomiting,  haematemesis,  and  melaena.  Notwithstand- 
ing careful  dieting  and  rest  in  bed  she  did  not  lose  her  symp- 
toms. She  was  seen  by  Dr.  Soltau  Fenwick,  in  consultation 
with  Dr.  Box.  and  a  diagnosis  of  appendix  trouble  was  made. 
I  opened  the  abdomen,  carefully  explored  the  stomach  and 
duodenum,  and  could  find  no  evidence  of  gastric  or  duodenal 
ulcer.  She  had  an  enormously  enlarged  appendix,  measuring 
33^2  inches  in  circumference,  and  containing  three  large  foul- 
smelling  concretions.  After  the  removal  of  the  appendix 
(October,  [909)  she  was  better,  but  still  suffered  from  acidity. 
For  some  months  she  remained  fairly  well,  and  then,  in  May, 
1010,  became  suddenly  worse,  and  brought  up  about  a  pint 
of  bright  blood.  In  July  she  had  several  attacks  of  haematem- 
esis and  mela?na,  two  of  them  severe.  The  pain  and  the 
hamorrhage  pointed  so  strongly  to  duodenal  ulcer  that  in 
September,  19IO,  I  again  opened  the  abdomen,  and  on  this 
occasion  found  a  duodenal  ulcer  adherent  to  the  liver.  A 
posterior  gastrojejunostomy  was  performed,  and  the  patient 
has  been  completely  relieved  of  all  her  symptoms." 

It  is  in  cases  of  severe  haemorrhage  disclosed  either 
by  haematemesis  or  by  melaena  that  the  greatest  diffi- 
culty of  diagnosis  may  arise.  I  have  twice  been  asked 
!<i  see,  with  a  view  to  immediate  operation,  patients 
who  voided  blood  by  the  stomach  or  by  the  bowel  in 
such  large  and  repealed  quantities  as  to  lead  to  the 
belief  thai  life  was  imperilled.  In  both  the  diagnosis  of 
duodenal  ulcer  had  been  made,  partly  because  the 
greater    portion    of    the    blood    had    been    passed    by    the 

rectum,  and  partly  because  some  vague  history  of  ill- 
health  and  "dyspepsia"  bad  preceded  the  onsel  oi  the 
haemorrhage.     In  both  cases  I  was  saved  from  an  error 


156  Duodenal  Ulcer 

in  diagnosis  by  a  careful  enquiry  into  the  anamnesis 
and  by  examination  of  the  abdomen,  for  in  both  I 
discovered  an  enlarged  spleen,  and  in  both  the  "dyspepsia  " 
was  not  of  the  kind  I  have  been  led  to  associate  with 
ulceration  of  the  stomach  or  duodenum.  Both  cases 
proved  to  be  examples  of  Banti's  disease,  and  in  one  case 
I  eventually  removed  the  spleen  and  demonstrated  the 
integrity  of  the  duodenum.  Splenic  anaemia  is  there- 
fore the  one  condition  it  is  supremely  important  to 
bear  in  mind  in  eases  of  severe  hsematemesis  or  melaena, 
especially  in  those  instances  in  which  the  characteristic 
disturbances  of  digestion  are  absent  or  inconspicuous. 
In  Banti's  disease  the  examination  of  the  blood  dis- 
closes a  persisting  anaemia  of  the  secondary  type.  In 
the  haemorrhages  which  result  from  a  simple  or  organic 
lesion  in  the  stomach  or  duodenum  the  blood  changes 
are  transient. 

I  have  once  made  the  serious  mistake  of  operating 
upon  a  patient  who  had  had  repeated  attacks  of  haemat- 
emesis  and  melsena,  the  cause  of  which  I  believed  to 
be  an  ulcer  near  the  pylorus  in  the  stomach  or  duodenum. 
The  patient's  life  had  more  than  once  been  in  jeopardy. 
I  could  discover  no  cause  for  the  haemorrhage,  and  the 
bleeding  continued  from  the  intestine  and  from  the 
wound  till  death  occurred.  The  patient's  mother  then 
informed  us  of  the  fact,  which  she  acknowledged  to  have 
concealed  deliberately  at  the  patient's  request,  that  her 
son  was  a  "bleeder."  The  genealogical  chart  was  char- 
acteristic: three  men  in  two  generations  had  died  of 
haemorrhage,  which  submitted  to  no  control. 

There  arc  cases  <>1  cirrhosis  of  the  liver  in  which  some 


Differential  Diagnosis  157 

slender  doubt  may  possibly  exist  as  to  the  presence  of  a 
gastric  or  duodenal  ulcer.  More  especially  is  this  the 
case  if  the  patient  has  been  a  hard  drinker  and  has  bled 
freely  from  the  stomach  or  bowel.  The  alcoholic  gas- 
tritis gives  rise  to  protracted  dyspepsia,  and  it  is  from 
dilated  veins  in  the  oesophagus  or  stomach  that  the 
haemorrhage  comes.  A  strict  enquiry  into  the  anam- 
nesis will  quickly  dispel  the  doubts  which  may  at  first 
be  entertained. 


CHAPTER  VIII 
THE  TREATMENT  OF  CHRONIC  DUODENAL  ULCER 

In  my  opinion  the  treatment  of  a  chronic  duodenal 
ulcer  should  always  be  surgical.  Chronicity  in  an  ulcer 
is  attested  by  the  recurrence  of  "attacks"  of  a  well- 
defined  character.  When  a  series  of  these  attacks  have 
occurred,  the  ulcer  is  always  to  be  plainly  seen  and 
demonstrated ;  and  my  experience  in  a  long  series  of 
operations  is  that  the  conditions  in  the  ulcer  are  such 
that  nothing  but  surgical  treatment  could  possibly  avail. 
The  ulcer  is  so  large,  or  so  indurated,  or  the  ulcers  are 
so  numerous,  that  even  if  the  lesions  were  to  cicatrise 
completely  one  of  two  things  would  result:  either  a 
hard,  fibrous  surface,  readily  breaking  down  under  pro- 
vocation, would  remain,  or  a  stenosis  of  the  bowel  would 
inevitably  follow. 

But  the  question  at  once  arises  as  to  when  the  case  is 
first  to  be  recognised  as  surgical,  as  to  when  we  are 
entitled  to  say  that  medical  treatment  will  probably 
prove  to  be  of  little  or  no  permanent  value.  What  are 
the  conditions  present  in  the  duodenum  in  the  first  of 
all  the  "attacks"?  I  have  at  present  no  means  of 
knowing.  I  have  only  once  operated  in  or  after  a  first 
attack,  and  so  have  little  evidence  upon  the  point.  I 
have  once  operated  at  the  close  of  a  second  attack, 
the  patient  being  referred  to  me  by  my  colleague,  Dr. 

158 


The  Treatment  of  Chronic  Duodenal  Ulcer  159 

T.  Wardrop  Griffith.  An  ulcer  about  14  inch  in  diam- 
eter on  the  anterior  surface  of  the  duodenum  was 
excised.  The  ulcer  was  clean,  with  terraced  margins, 
it  was  indurated,  and  it  had  destroyed  the  whole  of  the 
muscular  coat  of  the  bowel.  Though  the  attack  had 
passed  away  completely,  the  ulcer  was  still  open  and 
unhealed.  In  subsequent  attacks  the  ulcer  is  always 
to  be  seen  or  felt  and  possesses  the  characteristic  appear- 
ance. An  ulcer  which  has  caused  recurrent  attacks 
has  always  involved  the  serous  coat,  and  is  accordingly 
easily  to  be  seen  from  without.  It  is  only  when  attacks 
recur  that  a  diagnosis  of  chronic  duodenal  ulcer  can 
confidently  be  made;  it  is  only  when  this  diagnosis  can 
be  made  that  surgical  treatment  is  necessary.  In  a  first 
attack,  or  even  in  a  second,  medical  treatment  may  be 
tried.  But  I  believe  it  to  be  true  to  say  that  the  signi- 
ficance of  the  symptoms  in  these  attacks  has  never  yet 
been  fully  recognised  by  the  physician.  It  has  not  been 
realised  that  these  symptoms  are  due  to  a  structural 
lesion,  and  consequently  (after  a  diagnosis  of  "acid 
gastritis"  or  "neurosis")  treatment  has  been  perfunc- 
tory and  brief.  Up  to  the  present  time  it  is,  with  the 
exception  of  the  single  case  I  have  mentioned,  only 
after  repeated  attacks,  sustained  often  over  a  period 
of  years,  thai  the  surgical  need--  of  the  case  have  been 
recognised.  If  the  first  of  the  attacks  be  due  to  a 
duodenal  ulcer,  then  medical  treatment  of  a  sufficiently 
protracted  and  careful  character  should  be  tried.  Bu1 
when  attacks  recur  in  the  typical  manner  I  have  de- 
scribed, the  lesion  found  is  of  such  a  nature  that  .un- 
tiling other   than   surgical    treatment    i--   not    worth   con- 


160  Duodenal  Ulcer 

sidering.  It  is  safer,  speedier,  and  more  certain  than 
any  other  mode  of  treatment. 

I  do  not  desire  to  say  that  at  the  very  commencement 
of  this  disease  medical  treatment  is  futile.  Of  the  exact 
conditions  present  in  the  duodenum  in  the  earlier 
attacks  we  possess  no  information.  It  may  be  that 
a  condition  of  congestion,  or  of  superficial  mucous 
ulceration  visible  only  from  the  interior,  is  present.  If 
so,  surgical  treatment  is  not  to  be  considered.  But  a 
better  opinion  upon  the  most  suitable  method  of  treat- 
ment of  such  cases  may  be  expressed  when  we  possess 
some  more  accurate  information  of  the  pathological 
conditions  which  are  present  at  this  stage  of  the  disorder. 

It  must,  however,  be  admitted  that  medical  treat- 
ment, rest,  restriction  of  diet,  the  administration  of 
olive  oil,  and  other  similar  measures  can  soon  relieve 
the  severity  of  an  attack,  and  in  many  cases  abolish 
the  symptoms  for  shorter  or  longer  periods.  And  when 
these  things  have  happened,  the  ulcer  is  said  to  be  healed, 
and  the  patient  to  be  "cured."  In  a  large  number  of 
cases,  however,  this  improvement  is  not  permanent;  the 
symptoms  recur  under  the  various  provocations  which 
have  been  mentioned.  Relief  of  an  "attack"  in  a  case 
of  chronic  duodenal  ulcer  is  easy;  a  cure  of  the  con- 
dition by  medical  means  is,  I  believe,  almost  impossible. 

THE  SURGICAL  TREATMENT  OF  CHRONIC  DUODENAL  ULCER 

The  procedure  to  be  adopted  by  the  surgeon  in  the 
operative  treatment  of  a  chronic  duodenal  ulcer  will 
depend  upon  the  conditions  disclosed  at  the  time  the 
examination  of  the  lesion  is  made.      If  the  ulcer  is  small, 


The  Treatment  of  Chronic  Duodenal  Ulcer  161 

placed  on  the  anterior  surface  of  the  duodenum,  and  free 
from  adhesions,  it  may  safely  be  excised,  and  the  wound 
in  the  duodenum  closed.  If  the  ulcer  is  large  and 
indurated,  occupying  perhaps  more  than  half  of  the 
circumference  of  the  gut,  or  if  multiple  ulcers  are  found, 
or  two  ulcers  of  the  "kissing"  variety,  then  gastro- 
enterostomy will  be  necessary.  If  the  ulcer  is  associated 
with  a  chronic  gastric  ulcer  near  the  pylorus,  and  perhaps 
in  other  circumstances,  the  resection  of  the  affected 
area  may  be  necessary.  In  two  cases  when  the  ulcer 
was  small  and  did  not  affect  the  first  half  inch  of  the 
duodenum  I  resected  the  ulcer  and  a  cylinder  of  the  gut, 
closed  the  distal  end,  and  attached  the  proximal  end  to 
the  side  of  the  second  portion  of  the  duodenum,  mak- 
ing, that  is,  an  end-to-side  anastomosis.  In  certain 
cases  the  excision  of  the  ulcer,  followed  by  the  perform- 
ance of  Finney's  operation,  may  be  necessary. 

In  the  very  great  majority  of  cases  the  operation  of 
gastro-enterostomy  is  the  most  applicable,  and,  in  its 
results,  the  most  satisfactory.  But  in  order  that  it 
should  give  not  only  immediate  but  also  permanent 
relief,  the  ulcer  must  be  so  large  as,  either  in  its  present 
form,  or  by  the  time  healing  is  complete  in  it,  to  offer 
obstruction,  or  means  must  be  taken  to  secure  the 
infolding  of  the  ulcer.  Cases  have  been  recorded  by 
Kocher,  Quenu,  and  others  in  which,  after  gastro- 
enterostomy has  been  performed,  apparently  with  suc- 
cess, the  symptoms  returned,  and  death  occurred  from 
haemorrhage  or  from  perforation.  (See  also  Eve,  "Lan- 
cet," [908,  i,  [822.)  Riedel  ("Deut.  med.  Woch.," 
[909,   i,    17     has  recorded    two  cases  of  perforation  ol 


162  Duodenal  Ulcer 

ulcers  after  the  successful  performance  of  gastroenter- 
ostomy. We  know  by  clinical  observation  and  by 
experiment  that  a  gastroenterostomy  opening  is,  as  a 
rule,  a  free  outlet  from  the  stomach  only  when  some 
obstruction  to  the  onward  passage  of  the  food  exists  (see 
"Brit.  Med.  Journal,"  1908,  i,  1092).  A  duodenal  ulcer 
causes  such  impediment  either  because  it  lessens,  by 
reason  of  the  cicatricial  processes  engaged  in  it,  the 
lumen  of  the  intestine,  and  prevents  the  intestine  from 
distending  when  food  is  ready  to  pass;  or  because,  like 
other  lesions,  gall-stones,  appendicitis,  tuberculous  dis- 
ease of  the  intestine,  etc.,  it  excites  a  spasm  of  the 
pylorus.  The  former  of  these  is  permanent,  and  prob- 
ably tends  slowly  to  increase;  the  latter  is  transient 
and  disappears  as  soon  as  the  exciting  cause  is  removed. 
In  such  cases  a  gastro-enterostomy  opening  which  has 
acted  well  as  an  outlet  from  the  stomach,  and  has  in 
this  way  allowed  the  ulcer  beyond  the  natural  pylorus 
to  heal,  may  cease  to  act  when  the  ulcer  is  soundly 
healed.  If  that  ulcer  is  small,  its  scar  may  be  incon- 
spicuous and  offer  little  or  no  obstacle  to  the  easy  escape 
of  food.  The  pylorus  then  again  transmits  all  or  much 
of  the  food,  the  ulcer  subjected  to  renewed  irritation 
breaks  down,  and  the  symptoms  are  repeated.  The 
last  state  of  the  patient  is  the  same  as  the  first.  That 
this  is  not  mere  hypothesis,  one  case  at  least  upon 
which  I  have  myself  operated  (Case  173)  shews,  I 
believe,  quite  clearly.  It  is  in  my  judgment,  therefore, 
always  desirable  to  infold  such  an  ulcer.  A.  B.  Mitchell, 
of  Belfast,  has  shewn  that  this  produces  very  much  the 
same  effect  as  excision.     The  ulcer  is  soon  removed  and 


The  Treatment  of  Chronic  Duodenal  Ulcer  163 

an  intact  mucosa  remains.  Perforation  and  haemor- 
rhage are  prevented,  and  recurrence  of  the  ulcer  need 
not  be  feared.  The  lumen  of  the  gut,  moreover,  is 
permanently  narrowed,  and  the  gastro-enterostomy 
opening  becomes  the  chief  and  constant  outlet  from  the 
stomach. 

Excision  of  a  duodenal  ulcer  can  be  safely  performed 
only  when  the  wound  which  remains  after  removal  of 
the  ulcer  can  be  sutured  without  any  present,  or  the 
risk  of  future,  narrowing.  It  is  rare  for  a  case  to  be 
submitted  to  the  surgeon  in  an  early  stage;  the  lack  of 
acquaintance  with  the  clear  and  characteristic  symp- 
toms of  the  disease,  the  wide-spread  but  erroneous 
belief  that  persistent  hyperchlorhydria  is  a  "functional" 
rather  than  an  "organic"  disease,  result  in  a  delay  which 
is  both  unnecessary  and  dangerous.  By  the  time  an 
operation  is  performed  the  ulcer  is  usually  large,  puck- 
ered, indurated,  or  adherent,  and  excision  is  no  longer 
possible.  There  is,  however,  a  prospect  ol  1  tetter  things, 
and  in  the  future  the  excision  of  small  duodenal  ulcer-. 
small  because  discovered  early,  may  become  the  usual, 
a-  ii   i-  certainly  the  mosl  desirable,  procedure. 

In  the  two  eases  to  which  I  have  referred,  in  which 
the  resection  of  a  short  cylinder  of  the  duodenum,  fol- 
lowed by  an  end-to-side  anastomosis,  was  adopted,  I 
was  tempted  to  try  this  new  procedure  because  it 
enabled  me  to  preserve  intact  the  normal  action  <>l  the 
pylorus  during  digestion.  The  importance  and  the 
significance  of  this  mechanism  are  amply  illustrated  in 
the  work  of  Pawlow,  and  it  seemed  to  me  that  if  this 
function  could  be  preserved  it  would  be  an  advantage. 


164 


Duodenal  Ulcer 


Further  experience  of  it  is  necessary  before  anything 
can  be  said  as  to  the  permanence  of  the  results  which 
follow  its  use. 

The  following  are  the  methods  of  treatment  open  to 
the  surgeon : 

1.  Excision  of  the  ulcer.  Simple  excision.  Finney's 
operation. 


I  n..  27. — Excision  of  a  Duodenal  Ulcer  with  the  Cylinder  of  Bowel 
in  which  it  Lies. 

To  be  followed  by  end-to-end  or  end-to-side  anastomosis. 


2.  Gastro-enterostomy. 

3.  Resection  of  the  duodenum,  with  or  without  the 
pyloric  portion  of  the  stomach. 

4.  Resection  and  end-to-side  anastomosis,  the  pylorus 
being  left  intact. 

1 .  Excision  of  the  Ulcer. — The  abdomen  being  opened 
and  the  parts  inspected,  the  duodenum  is  brought 
well  up  into  the  wound.      In  most  cases,  since  the  ulcer 


The  Treatment  of  Chronic  Duodenal  Ulcer  165 

is  small  and  free  from  adhesion,  the  first  part  of  the  gut 
can  be  brought  easily  within  reach,  and  can  be  held 
securely  by  the  fingers  of  an  assistant  during  the  sub- 
sequent manoeuvres.  As  soon  as  the  gut  is  well  placed, 
hot  moist  swabs  are  packed  around  it,  so  that  any  fluid 
which  may  escape  from  the  duodenum  is  caught  at  once 


Fig.  28. — Excision  of  a  Duodenal  Ulcer. 
The  <li-t.il  cut  end  of  the  duodenum  is  closed,  and  an  end-to-side  anastomo- 
tic performed. 


l>v  them  and  prevented  from  soiling  any  part  of  the 
wound  edges  or  of  the  \  iscera.  This  packing  cannot  be 
tod  carefully  done.  The  pyloric  part  <>l  the  stomach  is 
then  drawn  out  of  the  abdomen  and  held  by  an  assist- 
ant against  the  lefl  margin  of  the  wound,  in  such  manner 
as  to  prevenl  any  fluid  contents  from  escaping   freely. 


1 66 


Duodenal  Ulcer 


The  ulcer  is  then  surrounded  by  two  horizontal  incisions 
enclosing  an  ellipse  between  them.  The  incisions  are 
carried  through  all  the  coats  of  the  gut  and  the  ulcer  is 


FlG.    29. — GASTRO-ENTEROSTO\n  . 
The  transverse  mesocolon  has  been  incised  and  the  posterior  surface 
of  the  stomach  is  made  to  project  through  the  opening.     The  vessels  of 
the  greater  curvature  are  seen  immediately  beneath  the  thumb. 

removed.  At  the  middle  of  the  upper  and  lower  margins 
of  the  incisions  a  fine  vulsellum  forceps  is  placed;  on 
drawing  these  two  apart,  the  incision,  which  before  was 


The  Treatment  of  Chronic  Duodenal  Ulcer  167 

horizontal,  now  becomes  vertical,  and  in  this  direction 
it  is  sutured.  I  prefer  to  use  tine  catgut  for  the  inner 
stitch,  which  is  introduced  in  the  "loop  on  the  mucosa" 
method.     A  fine  edge  of  all  the  coats  is  thus  inverted. 


<\*jj_  VU 

fjfesi^ 

w£^ 

y 

- 

■ 

i 

Fig.  30.     Gasi  ro-en  rEROSTOMYi 
The  clan]])  is  applied  vertically  to  the  stomach. 

The  catgut  suture  is  drawn  tight  so  as  to  secure  .ill  cut 
vessels  in  the  edge.  This  line  of  suture-  is  then  infolded 
1)\-  a  continuous  stitch  of  fine  Pagenstecher  thread. 
It  is  important  to  secure  a  good  apposition  <>i  serous 
surfaces,  and  yet   it  is  equally  important   to  avoid  the 


168  Duodenal  Ulcer 

turning  in  of  too  broad  a  surface,  lest  subsequent  stenosis 
result.  The  operation  is  then  complete,  and  the  swabs 
are  removed,  the  viscera  returned,  and  the  abdominal 
wound  closed.  This  procedure  may  be  varied  by  per- 
forming a  wider  excision  of  the  ulcer,  and  by  continuing 
the  ends  of  the  horizontal  incisions  well  to  each  end,  into 
the  stomach  and  on  to  the  second  part  of  the  duodenum. 
The  large  wound  which  results  is  then  sutured  after  the 
manner  adopted  in  Finney's  operation. 

2.  Gastro-enterostomy. — In  all  cases  of  simple  duo- 
denal ulcer  the  posterior  operation  (von  Hacker's 
method)  can  be  performed.  In  my  judgment  the  pos- 
terior no-loop  operation  with  a  vertical  application  of 
the  jejunum  to  the  stomach  is  by  far  the  most  satis- 
factory procedure.  Various  hypothetical  objections  have 
been  brought  against  it,  but  they  have  not  been  sub- 
stantiated by  clinical  experience.  The  operation  is 
performed  in  this  manner:  An  incision  about  4  or  5 
inches  in  length  is  made  1  inch  to  the  right  of  the  middle 
line  above  the  umbilicus,  and  is  carried  at  once  down  to 
the  anterior  sheath  of  the  rectus,  which  is  divided.  The 
rectus  fibres  are  then  split  vertically,  or  the  inner  part 
of  the  sheath  is  dissected  up  from  the  front  of  the  muscle- 
belly  and  the  whole  muscle  displaced  outwards  from  the 
middle  line.  The  posterior  sheath  is  then  incised  and 
the  abdomen  is  opened.  The  skin  is  covered  by  "tetra 
cloth"  attached  by  special  forceps  to  the  wound  edges 
and  ends.  The  stomach,  duodenum,  and  gall-bladder 
are  then  examined  with  great  care.  The  immediate 
discovery  of  a  single  lesion  whose  existence  has  been 
anticipated   should    never   satisfy   the   surgeon.     There 


The  Treatment  of  Chronic  Duodenal  Ulcer  169 

may  be  more  lesions  than  one,  and  a  knowledge  of  their 
presence  and  whereabouts  may  be  necessary  to  the 
complete  relief  of  the  patient.  When  this  examination 
is  complete  and  the  need  for  gastroenterostomy  assured, 
the  stomach,  transverse  colon,  and  omentum  are  with- 
drawn from  the  abdomen  and  turned  upwards  to  expose 
the  under  surface  of  the  transverse  mesocolon.  The 
origin  of  the  jejunum  is  then  sought.  There  are  times 
when  the  first  few  inches  of  the  jejunum  are  attached 
to  the  under  surface  of  the  mesocolon  by  adhesions, 
possibly  physiological,  possibly  pathological.  The  meso- 
colic  band,  a  short  ligament  springing  from  the  under 
-urface  of  the  mesocolon  and  attached  to  the  jejunum 
below,  may  extend  on  to  the  gut  for  3  inches  or  more. 
If  so,  it  should  be  divided,  until  the  jejunum  is  free  up 
to  its  origin.  An  opening  is  then  made  through  the 
under  surface  of  the  mesocolon  at  a  bloodless  spot  close 
to  the  jejunal  origin,  and  the  opening  is  enlarged  towards 
the  transverse  colon  until  three  fingers  can  easily  be 
passed  through  into  the  lesser  sac.  Through  this 
opening  the  posterior  wall  of  the  stomach  is  pushed  by 
the  left  hand  of  the  surgeon  pressed  against  the  anterior 
wall.  It  is  essential  to  see  that  the  part  needed  for  the 
anastomosis  is  brought  through  the  opening.  This 
part  consists  of  a  vertical  fold  in  line  with  the  vertical 
part  of  the  lesser  curvature  'and  therefore  in  line  with 
the  righl  margin  of  the  oesophagus),  and  it  ends  below 
.11  the  lowesl  point  of  the  greater  curvature.  A  fold  of 
the  posterior  surface  along  this  line  is  then  seized  by  the 
fingers  of  the  surgeon  and  drawn  well  out  of  the  abdomen. 
This  is  quite  easily  done  in  most  patients,  but  duodenal 


170 


Duodenal  Ulcer 


ulcer  is  sometimes  found  in  fat,  sleek  patients  whose 
abdominal  wall  may  be  3  or  4  inches  in  thickness.  In 
them  it  may  be  difficult,  or  even  impossible,  and  the 
anterior  operation  may  alone  be  possible.  As  the  fold 
lies  in  the  grip  of  the  fingers  it  is  embraced  by  a  clamp 
applied  vertically;    the  handle  of  the  clamp  points  to 


I    I  'Coo 

Fig.  31. — Gastroenterostomy. 
The  two  clamps,  the  upper  on  the  stomach,  the  lower  on  the  jejunum, 
lie  side  In    side.     All  other  viscera  are  replaced  within  the  abdomen  and 
gauze  and  rubber  pads  surround  the  clamps  closely. 


the  pubes,  the  tip  of  the  blades  to  the  chin.  A  good 
fold,  3  or  4  inches  in  length,  is  held.  The  clamp  is  then 
gently  turned  until  it  is  almost  transverse,  the  handle 
being  towards  the  assistant.  Meanwhile  the  uppermost 
part  of  the  jejunum,  which  has  been  given  into  the 
assistant's  hands,  is  now  drawn  well  out  of  the  abdomen 
and   clamped.     The  clamp  is  applied   by  the  assistant 


The  Treatment  of  Chronic  Duodenal  Ulcer  171 

while  the  length  of  the  gut  is  held  up  by  the  surgeon ; 
when  the  clamp  is  in  position,  and  before  it  is  locked, 
the  jejunum  at  the  proximal  end  is  pulled  forwards  as 
taut  as  possible,  while  .the  clamp  is  depressed  by  the 
assistant  as  forcibly  as  can  be;  this  secures  that  the  gut 
as  close  as  possible  to  the  flexure  is  included  in  the  grip 
of  the  clamp.  All  viscera  are  now  returned  within  the 
abdomen,  the  stomach,  transverse  colon,  and  omentum 


^?r>«.\> 

uflHiv* 

^<r^ 

£***'> 

N^.m      j  > 

'y^  ■»■ 

~ 

'■<«=.                                             - 

fr 

<ta/  a  Xrt-Xr  ,<,„ 

\ 

FlG.    32. — GASTRO-ENTEROSTOM'i  , 
The  first  layer  of  sutures  introduced. 

being  passed  into  the  peritoneal  cavity  through  the 
part  of  the  incision  above  the  clamp.     The  clamps  alone 

are  now  outside  the  abdomen,  and  they  embrace  folds, 
about  3  or  4  inches  in  length,  of  the  stomach  and  jejunum, 
and  they  lie  horizontally.     They  are  surrounded  by  hoi 

moist    SWabs,  and    a    gaUZe  Strip  IS  placed   between   them. 

Swab-  made  of  a  sheel  of  dental  rubber  with  three  or 
four  thicknesses  of  gauze  on  each  side  are  the  best. 
There  is  accordingly  absolutely  no  exposure  of  viscera, 


172 


Duodenal  Ulcer 


and  any  leakage  of  blood  or  contents  from  the  stomach 
or  jejunum  has  no  possible  chance  of  reaching  the  wound 
edges  or  the  peritoneal  cavity.  The  union  of  the  two 
viscera  is  now  begun.  Two  sutures  only  are  used; 
both  are  continuous.  The  outer  suture  is  sero-muscular; 
the  inner  includes  all  the  coats.  The  needle  I  prefer  is 
a  curved  needle  of  my  own  pattern;  it  is  slender,  five- 
eighths  of  a  circle  in  its  curve,  has  a  slot  eye,  and  is 


Fig.  33. — Gastroenterostomy. 

The  viscera  are  now  incised  through  their  serous  and  muscular  coats.     The 

mucous  membrane  pouts  into  the  wound  and  is  then  excised. 


of  such  a  diameter  that  it  is  the  slightest  degree  thicker 
than  the  finest  Pagenstecher  thread  when  doubled. 
(These  needles  are  made  by  Downs  Bros.,  of  London.) 
This  needle  picks  up  almost  automatically  the  exact 
amount  of  the  viscera  that  is  necessary,  and  because  of 
the  relationship  between  its  thickness  and  that  of  the 
thread   which    it   carries   there   is   no    "pull"    necessary 


The  Treatment  of  Chronic  Duodenal  Ulcer  173 

when  the  thread  is  to  be  drawn  through  the  punctures 
which  the  needle  has  already  made. 

I  greatly  prefer  a  curved  needle.  If  a  surgeon  prac- 
tises with  it  a  few  times,  he  will  find  it  easier  to  use  than 
a  straight  one,  and  he  will  find  it  quicker  also.  But  it 
is  nece>sary  to  hold  the  needle  in  the  right  way. 

The  first  suture  is  now  introduced.  It  engages  the 
sero- muscular  tunics  of   the  viscera  and   begins   at   the 


I'k..  34.  -Gastroenterostomy. 
Tin-  inner,  through  and  through,  continuous  stitch  i-  here  begun. 


most  distant  end  from  the  surgeon,  and  i>  broughl 
towards  him.  After  the  firsl  stitch  the  suture  is  knotted ; 
afterwards  the  suture  run-  without  interruption  or 
alteration  until  the  whole  length  of  the  clamped  portions 
is  united.  It  is  at  the  tip  of  the  .lamp  th.it  the  greater 
curvature  of  the  stomach  lies,  and  care  is  necessary  to 
see  that  the  lowesl  pari  of  the  curvature  is  engaged  in 
the  suture.     The  large  vessels  which   are  -ecu  at    this 


174 


Duod 


enal 


Ulcer 


point  should  be  avoided,  or  included  in  the  needle  so  as 
to  secure  them  and  prevent  haemorrhage  from  their  cut 
ends.  As  the  suture  is  introduced  it  is  pulled  fairly 
tight,  so  as  to  bring  the  opposing  surfaces  snugly  to- 
gether. The  part  of  the  thread  between  the  last  stitch 
and  the  needle,  when  drawn  upon,  raises  up  a  little 
hillock  on  each  viscus,  shewing  where  the  next  insertion 
of  the  needle  is  to  be  made,  and  making  that  insertion 


*>*w 


Fig.  35. — Gastroenterostomy. 
The  inner  stitch  is  half  completed;  turning  the  corner. 


easier.  The  number  of  introductions  of  the  needle  is 
usually  about  eight  or  ten  to  the  inch,  and  at  least  2>^ 
inches  should  be  included  in  this  suture.  When  this 
first  line  is  completed,  the  needle  is  laid  aside  for  a  time. 
The  next  step  consists  in  opening  the  viscera  by  an 
incision  parallel  to  the  line  of  suture  just  completed. 
Before  the  opening  is  made,  a  few  loose  pieces  of  moist 
gauze  are  packed  round  to  catch  any  blood  or  discharge 
which    escapes.     The    incision    is   made   about    yi   inch 


The  Treatment  of  Chronic  Duodenal  Ulcer  175 

from  the  suture  line;  at  first  only  the  serous  and  mus- 
cular coats  are  divided ;  as  they  retract  the  mucosa  pouts 
into  the  wound,  broadly  in  the  centre,  narrowly  at  each 
extremity.  The  whole  of  this  strip  of  the  mucous 
membrane  is  exeised;  that  from  the  stomach  comes 
away  readily  in  one  pieee,  that  from  the  jejunum  gener- 
ally in  several  pieces.  At  each  end  of  the  jejunal  open- 
ing an  additional  triangular  piece  has  always  to  be  taken. 


FlG.    36.      I  I  ^STRO-ENTEROSTOMY. 

The  anterior  st itch  continued.     This  shews  the  method  of  introducing  the 

loop  in  the  mucosa  si  itch. 

After  the  openings  have   been  made  and   the  cavities 

wiped  clean  with  gauze,  an  Allis's  forceps  is  placed  at 
the  end  near  the  surgeon;  it  embraces  all  the  coats 
of  each  organ  and  form-  a  sorl  of  "basting  stitch." 
The  inner  suture  i-  now  introduced.  It  is  a  running 
stitch  which  picks  up  all  the  coal-  on  both  sides;  ii  is 
drawn  rather  tight,  so  as  to  act  a-  an  haemostatic  suture; 
the  separate  part-  of  it  are  placed  close  together  in 
order    to   ensure    that    no   considerable    vessel    escapes. 


176  Duodenal  Ulcer 

At    its    first    introduction    the    needle    passes    from    the 


Fig.  37. — Gastroenterostomy. 
The  anterior  stitch  applied  in  the  ordinary  manner.     This  results   in 
a  slight  eversion  ot  the  mucosa,  which  is  an  advantage.     This  is  the  stitch 
I  prefer. 


Fig.  38. — Gastro-entkrostomy. 

The  inner  stitch  completed.      The  outer  suture  continued. 

mucous  to  the  serous  surface  of  the  jejunum  in  the  angle 
at    the    left    extremity,    then    from    the    serous    to    the 


The  Treatment  of  Chronic  Duodenal  Ulcer  177 

mucous  surfaces  of  the  stomach;  when  the  knot  is  tied 
it  lies,  therefore,  upon  the  muco^  surface.  When  the 
right  extremity  of  the  openings  is  reached,  the  corner 
is  turned  and  the  suture  continued  along  the  anterior 
edges.  I  have  used  two  types  of  suture  for  the  return 
half — the  "loop  on  the  mucosa"  stitch,  or  the  ordinary 
running  suture  which  passes  from  serosa  to  mucosa  of 
the  jejunum,  and  then  from  mucosa  to  serosa  of  the 
stomach.     I  prefer  the  latter,  for  when  drawn  tight,  it 


^ 


FlG.    39.      <  .AM  RO-ENTEROSTOMY. 

Tin*  outer  stitch  in  the  acl  of  completion.     The  last  introduction  of  the 

needle  is  made  beyond  the  first  stitch. 


slightly  everts   the   mucosa,  so  that  when   the   clamps 

are  removed  any  small  bleeding  vessel  is  seen  at  once 

and    secured    by   a   separate   suture   or   by   a    ligature. 

When  the  "loop  on   the  mucosa"  stitch  is  used,  some 

vessel   may  escape   sufficienl   constriction,  and    ha^mat- 

emesis  max    be  the  result.     A  few  o\  my  patients  have 

vomited    blood   alter    I    had    used    this  suture;     it    was 

never  serious  in  any  ol  them,  bu1  such  an  evenl  should 
12 


178  Duodenal  Ulcer 

be    avoided    if    possible.     When    the    suture    has    been 


/Q09 


Fig.  40. — Gastroenterostomy. 

The  suture  line  completed.  The  viscera  are  lifted  out  from  the  ab- 
domen and  the  mesocolon  is  sutured  to  the  stomach  and  jejunum.  Note 
that  t  he  -1  itch  is  taken  a  little  distance  away  from  the  cut  edge  of  the  moo- 
colon,  so  that  the  frayed  edge  of  the  latter  is  turned  inwards  to  the  lesser 
sac  when  the  stitch  is  tied. 

continued  completely  round  the  margins  of  the  opening 
to  the  starting-point,  it  is  knotted  and  cut  short.     The 


The  Treatment  of  Chronic  Duodenal  Ulcer  179 

clamps  are  now  loosened,  but  are  left  in  position,  so  as 
to    prevent    the    viscera    from    slipping    back    into    the 


Fig.  41.    Gasi  ro-en  rEROsTi  tin 
The  opposite  side  of  the  anastomosis.     A  similar  mesocolic  suture  is  taken 

here. 

abdomen.  I!  any  bleeding  vessel  is  seen,  it  is  caughl 
.Hid  ligatured.  The  parts  are  then  wiped  a  iVw  times 
with   hot   moisl   gauze,   to  remove  all   Mood  or  gastric 


i8o  Duodenal  Ulcer 

discharge  that  may  perhaps  have  escaped;  the  gloved 
hands  of  the  surgeon  and  assistant  are  thoroughly 
rinsed,  and  all  instruments  used  up  to  this  point  are 
covered  over  with  a  clean  sterile  towel,  and  are  used 
no  more.  The  outer  sero-muscular  suture  is  now  re- 
sumed. The  needle  temporarily  laid  aside  is  taken  up 
and    the  suture  continued   from   the  greater  curvature 


I 


Fig.  42.  -Gastroenterostomy. 

Diagram  of  the  operation  complete.     There  i.^  no  jejunal  "loop,"  and  the 

opening  in  the  stomach  is  vertical. 

up  towards  its  original  starting-point  near  the  lesser 
curvature.  After  each  turn  of  the  needle  the  thread 
is  drawn  tight  and  a  ridge  raised  up  on  both  sides.  It 
is  into  these  ridges  that  the  needle  is  next  passed.  When 
the  suture  has  returned  to  the  starting-point,  a  single 
introduction  of  the  needle  is  made  beyond  the  first 
stitch,  so  as  to  overlap  it.     Before  the  last  two  or  three 


The  Treatment  of  Chronic  Duodenal  Ulcer  181 

turns  of  the  needle  it  is  well  to  remove  the  clamps,  to 
relieve  the  little  tension  of  the  jejunum  especially.  A 
greater  security  is  in  this  way  given  to  the  visceral 
opposition  at  the  end.  The  suture  lines  are  now  com- 
plete   and    the    anastomosis    is    made.     The    parts    are 


I  n..  1.3.— Antiperistaltic  Application  of  the  Jejunum  ro  mi    Stom- 

\i  11     I  [ochem 
When  the  stomach  is  replaced  in  its  normal  position,  the  jejunal  direction 
is  the  same  as  in  the  next  figure. 

wiped  once  again,  and  the  gauze  strip  which  lay  behind 
the  viscera  removed.  The  whole  suture  line  is  finally 
inspected. 

It  now  remains  to  close  the  opening  through  the 
mesocolon  into  the  lesser  sac.  This  is  done  by  passing 
three  or  lour  sutures,  which  pick  up,  on  the  one  hand, 


182 


Duodenal  Ulcer 


the  under  surface  of  the  mesocolon  about  Vi  inch  from 
the  edge,  and,  on  the  other,  the  stomach  and  jejunum 
exactly  at  the  suture  line.  When  each  stitch  is  tight- 
ened, the  free  rough  edge  of  the  mesocolic  opening  is 
rolled  inwards  to  the  lesser  sac,  so  that  only  a  smooth 
intact  surface  presents  below.  The  opening  into  the 
lesser  sac  is  thus  securely  closed,  all  rough  surfaces  are 


Fig.  44. — Gastroenterostomy. 

The  anastomosis  may  be  made  "antiperistaltic,"  the  jejunum  being  directed 

to  the  left  (after  W.  J.  Mayo). 

avoided,  and  the  suture  line,   though  it  does  not  need 
it,  is  materially  strengthened  and  supported. 

The  last  step  is  to  replace  the  viscera  and  to  infold 
the  duodenal  ulcer.  This  secure  closure  of  the  ulcer  I 
hold  to  be  most  necessary;  it  adds  nothing  to  the  risks 
of  the  operation,   takes  only  two  or  three  minutes   to 


The  Treatment  of  Chronic  Duodenal  Ulcer  183 

perform,  and  removes  the  contingency  of  a  later  disaster. 
A  few  interrupted  Lembert's  sutures  are  passed  from 
one  side  of  the  ulcer  to  the  other,  and  as  they  are  tight- 
ened the  ulcer  is  pushed  inwards  and  infolded  (Fig.  45). 
After  these  sutures  are  tied  the  gastro-hepatic  and  the 
gastro-colic  omentum  above  and  below  the  duodenum 


Fig.  45. — Infolding  of  a  Duodenal  Ulcer. 
Performed  .1-  a  matter  of  routine  after  the  gastro-enterostomj  is  com- 
pleted, and  followed  by  the  suture  or  ligature  of  the  gastro-hepatic  and 
gastro-colic  omenta  over  the  duodenum. 

are  drawn  together  by  suture  .or  by  ligature  so  as  to 
form  an  additional  covering  and  protection  to  the 
infolded   ulcer.     It    is  important    to  remember  thai    in 

cases  of  duodenal  ulcer  both  perforation  and  haemor- 
rhage have  proved  fatal  after  gastro-enterostom)  has 
been   performed,  and   has  been   followed  by   temporary 

ini|>i'o\  ement . 


184  Duodenal   Ulcer 

There  have  been  differences  of  opinion  as  to  the 
exact  line  along  which  the  attachment  of  the  jejunum 
to  the  stomach  should  be  made.  Surgeons,  also,  wear 
their  rue  with  a  difference.  There  does  not  in  practice 
seem  to  be  much  to  choose  between  the  results  of  one 
method  and  of  the  other:  the  one  essential  is  that  the 
operation  should  be  practised  only  in  those  cases  where 
there  is  a  clear  indication  of  its  necessity.  Hochenegg 
advised  that  in  applying  the  jejunum  to  the  posterior 
wall  of  the  inverted  stomach  the  bowel  should  be  placed 
in  such  a  direction  that  the  line  of  the  ascending  portion 
of  the  duodenum  was  continued  without  any  break;  in 
this  way  a  no-loop  antiperistaltic  anastomosis  is  made. 
The  antiperistaltic  method  has  also  been  advocated 
by  W.  J.  Mayo;  it  has  accordingly  met  with  wide  adop- 
tion, and  has  been  followed  by  equally  satisfactory 
results. 

In  addition  to  the  performance  of  gastroenterostomy 
and  the  infolding  of  the  ulcer,  one  thing  more  needs  to 
be  done,  if  possible,  in  all  cases  of  duodenal  ulcer.  The 
appendix  should  be  removed.  In  approximately  three 
out  of  four  cases  in  my  practice  of  the  last  two  or  three 
years  there  has  been  an  ample  warrant  for  this  course 
in  the  diseased  condition  of  this  little  organ.  In  many 
cases  the  changes  in  it  are  of  a  serious  and  advanced 
character.  It  may,  I  think,  justly  be  held  that  all 
cases  of  duodenal  ulcer,  as  of  gastric  ulcer  and  of  gall- 
stones, are  "secondary."  They  are  the  result,  that  is 
to  say,  of  some  infection,  or  of  some  toxaemia,  which  has 
its  origin  for  the  most  part  in  some  abdominal  organ. 
The  evidence  has  seemed  to  me  to  be  strongly  in  favour 


The  Treatment  of  Chronic  Duodenal  Ulcer  185 
of  supposing  that  this  source  of  infection  in  many  cases 

* 

is  the  appendix;  in  some  it  is  in  the  small  intestine; 
in  some  in  the  large;  in  some  in  the  pelvic  organs  of 
the  female;  in  some  in  parts  outside  the  abdomen.  A 
routine  examination  of  the  abdomen  should  follow  the 
direct  dealing  with  the  stomach  in  all  cases  of  duodenal 
ulcer  if  the  patient's  condition  permits  this  to  be  done 
with  safety.  It  is  remarkable  with  what  frequency  one 
then  discovers  a  gross  lesion  in  the  appendix.  I  there- 
fore make  it  a  practice,  with  few  exceptions,  to  examine 
and  remove  the  appendix  in  all  cases  of  gastric  and 
duodenal  ulcer  and  of  gall-stones.  As  an  illustration  of 
the  frequency  and  extent  of  the  changes  found  in  the  ap- 
pendix I  selected  haphazard  the  first  12  cases  of  chronic 
ulcer  operated  upon  in  the  year  191 1.  The  figures  wen' 
drawn  during  or  immediately  after  the  operation  in 
every  case.     (See  Fig.  46.) 

In  a  very  small  proportion  of  the  cases  the  kink 
in  the  lower  end  of  the  ileum,  described  by  Arbuthnot 
Lane,  is  found.  It  is  generally  not  of  much  obvious 
importance  in  so  far  as  the  impediment  to  the  onward 
passage  of  intestinal  contents  is  concerned.  But  in  all 
cases  it  is  best  to  divide  it,  and  by  a  few  stitches,  or 
by  the  smearing  over  of  sterilised  vaseline,  to  endeavour 
to  prevent  its  reformation.  In  about  one-third  of  my 
cases  a  long  mesocolic  band,  or  some  slender  adhesion, 
is  found  attaching  the  jejunum  to  the  under  surface  ol 
the  mesocolon.  The  purpose  of  the  ligamenl  ol  Treitz 
i-  surely  to  allow  a  very  mobile  portion  ol  the  intestine, 
continuous  with  an  absolutely  fixed  portion,  so  to  move 
from   side   to  side,   in   any   direction,    thai    no   kink   or 


cu  / 


i 


.  ■■«    5 


Oi-w'     fc 


kfcee    /? 


(jLa-    /2 


Fig.  46.— Drawings  01    rnu  Appendix  ///  .s'/7»  in  Twelve  Successive 
Cases  Operated  Upon  for  Gastric  or  Duodenal  Uixer. 
All  except  No.  9  shew  extensive  adhesions — No.  9  was  markedly  con- 
ed in  its  terminal  inch  and  one-half  and  contained  two  solid  bodies  in 
this  part.     Nos.  3  and  12  contained  many  solid  bodies.     Nos.  5,  7,  and  8 
are  most  interesting;  in  these  the  appendix  is  divided  by  fibrous  bands 
into  two  distinct  pieces.     Nos.  6'and  12  shew  diverticula.     In  all  except 
No.  7  there  was  a  duodenal  ulcer  present;   in  No.  7  the  ulcer  was  on  the 
lesser  curvature  of  the  stomach,  and  in  Nos.  8  and  11  there  were  both  duo- 
denal and  gastric  ulcers. 

186 


The  Treatment  of  Chronic  Duodenal  Ulcer  187 

obstruction  is  produced  at  the  point  of  junction.  It  is 
very  rare,  indeed,  to  find  any  evidence  of  duodenal 
stasis  in  these  cases,  examined  by  x-rays  after  a  bismuth 
meal.  It  is  certain  that  in  my  earlier  cases  I  overlooked 
the  presence  of  "Lane's  kink"  in  some  instances,  for 
it  is  only  recently  that  I  have  systematically  searched 
for  it  in  cases  of  gastric  and  duodenal  ulcer,  gall-stones, 
or  appendicitis.  In  cases  of  duodenal  ulcer  it  is  present 
in  about  5  per  cent.  '4  times  in  87). 


Fig.  47.     Anterior  i  i  istro-enterostomv 

After-treatment.     As   soon    as   the   operation    is   com- 
pleted the  patient  is  placed  in  a  warm  bed.  lying  on  the 
back  with  one  pillow.     Alter  an  hour  or  two     as  ^>on. 
that  is,  as  the  eflfee.1  of  the  anaesthetic  is  passing  ofl 
the   patient    is  propped   up  in   bed   with   a   bed-resl   or 


1 88 


Duodenal  Ulcer 


five  or  six  pillows.  The  position  is  one  of  great  comfort 
to  the  patient,  but  it  is  difficult  to  maintain.  There  is 
a  very  marked  tendency,  for  a  heavy  man  particularly, 
to   slide   down    in    the   bed.     A   most    useful    device   for 


Fig.  48. — Gastroenterostomy,  Roux's  Operation. 
The  distal  end  of  1  he  jejunum  is  here  united  to  1  he  stomach  —an  end-to-side 

anastomosis. 

keeping  the  patient   in  the  sitting  position  is  that  sug- 

ted  by  Dr.  ('aims  Forsyth.     A  hard,   round  pillow, 

covered   with   mackintosh   and   a   pillow   slip,   is  placed 

beneath    the   patient's    thighs,    immediately    below    the 


The  Treatment  of  Chronic  Duodenal  Ulcer  189 

buttocks.  To  each  end  of  this  pillow  a  stout  strap  is 
attached,  terminating  in  a  buckle.  A  second  strap  i> 
fixed  to  the  upright  end  of  the  bed,  and  its  lower  end 
engages  with  the  buckle  attached  to  the  pillow;  by 
pulling  this  strap  tight  and  fixing  it,  the  position  of  the 
pillow  is  made  secure.     The  patient  is  supported  by  this 


Fn..  49.  -Roux's  Operation  (Complete). 


pillow  quite  comfortably,  and  i-  prevented  from  slipping 

down  in  the  bed.  About  five  or  >i\  hours  after  the  oper 
ation  the  feeling  of  nausea  caused  by  the  ether  will 
have  passed  off,  and  the  patient  begins  to  ask  for  fluid. 
At  once  water  is  given,  an  ounce  or  more  .it  a  time  to 
begin  with,  and  in  two  or  three  hours  a  cup  of  tea. 
Mosl    patients    like    tea    better    than    any    other    drink; 


190 


Duodenal  Ulcer 


during  the  first  twenty-four  hours  three  or  four  cups, 
made  to  the  patient's  liking,  may  be  given.  I  do  not 
restrict    the    quantity    of    water    allowed    to    patients. 


Fig.  50. — Modification  of  Roux's  Operation  as  Performed  by  the 

Author. 
The  jejunum  is  divided  between  a  rubber-covered  clamp  and  a  Parker- 
Kerr  clamp.      It  is  cut  across  with  the  knife  passed  as  close  as  possible  to 
the  latter.     The  division  is  carried  on  into  the  mesentery. 

They  rarely  drink  more  than  20  or  30  ounces  in  the 
first  twenty-four  hours,  but  it  is  their  own  desire  which 
regulates  the  quantity  given,    not  any  order  of   mine. 


The  Treatment  of  Chronic  Duodenal  Ulcer    191 

There  is  no  harm  done  by  giving  fluids  freely.  If  a 
patient  can  vomit  without  injury  to  the  suture  line,  it 
is  quite  certain  that  the  passage  of  fluids  through  the 
anastomotic  opening  will  do  no  hurt.  For  the  last  three 
or  four  years  I  have  put  no  restraint  upon  patients  in 
this  matter,  even  from  the  first.  Thirst  is  the  most 
intolerable  of  all  sufferings  after  abdominal  section,  and 
there  is  no  justification  for  allowing  a  patient  to  suffer 
from  it.  Fluid  taken  by  the  mouth  has  to  pass  to  the 
large  intestine  to  be  absorbed.  The  intestines  are  kept 
active,  therefore,  and  this  is  entirely  an  advantage.  I 
do  not  order  solid  food  until  a  patient  himself  asks  for 
it.  In  the  early  days  milk,  soups,  tea,  and  cocoa  are 
given  freely,  but  solid  food  is  not  desired  by  a  patient 
until  eight  or  ten  days  have  passed.  As  soon  as  the 
request  is  made  I  grant  it,  ordering  sweetbread,  fish, 
bread  and  butter,  mince,  and  so  on,  and  the  quantities 
taken  are  not  restricted.  In  eighteen  or  twenty  days 
ordinary  food  can  be  taken  and  enjoyed.  I  discourage 
pastry,  fresh  fruits,  and  green  vegetables  in  all  cases 
for  some  time,  for  these  things  are  without  value  as 
foods. 

On  the  night  of  the  operation  the  patient  may  be 
allowed  ,'  gr.  of  morphine  hypodermically.  Then'  is 
usually  not  much  pain  after  an  operation  involving  the 
stomach;  but  if  the  patient  complains  of  pain,  I  do  not 
hesitate  to  give  one  hypodermic  injection  of  morphine. 
It  is  extremely  rare  lor  a  second  <1m~c  i,,  |,r  asked  for  or 
to  l>e  given.  In  all  cases  .1  simple  enema,  with  or  with- 
out turpentine,  is  given  twenty-four  hours  after  opera- 
tion.    Flatus  i--  broughl  away,  and  the  patienl  i-  more 


' 

rg 

*N 

Fig.  51. — Modification  of  Roux's  Operation. 
Closure  of  the  distal  end  of  the  jejunum.  In  the  figures  the  bowel 
should  not  be  seen  protruding  between  the  blades  of  the  1  lamp.  The 
stitch  is  taken  parallel  to  the  blade,  first  on  one  side,  and  then  on  the  other 
On  reaching  the  tip  of  the  clamp,  the  clamp  is  loosened  and  removed  and 
the  stitch  quickly  drawn  tight;  the  edges  of  the  gut  are  rolled  inwards  and 
the  stitch  now  returns  to  the  starting-point,  where  it  is  tied  and  cut  short 
(After  Parker  and  Kerr's  method.) 


192 


The  Treatment  of  Chronic  Duodenal  Ulcer     193 

comfortable.     An    aperient,    castor    oil    or    calomel,    is 
given  about  the  fifth  day.     Several  times  daily  the  teeth 


1    v* 

V 

; 


Fig.  52.     Modification  oi    Roux's  Operation. 
After  closure  of  the  distal  end  of  the  jejunum,  gastroenterostomy  is 
performed.     The  proximal  cut  end  of  the  jejunum  is  then  united  to  the 
side  of  the  distal  end,  about   4  inches  below  the  anastomosis  with  the 
stomach. 


are  brushed  and  the  mouth  rinsed  with  some  fragrant 
wash,  Mich  as  glycothymoline  or  listerine  or  odol.     The 
1  ? 


194  Duodenal  Ulcer 

patient  is  allowed  up  some  time  during  the  second  week 
usually  on  the  ninth  or  tenth  day. 

3.  Resection  of  the  Duodenum,  With  or  Without  a 
Portion  of  the  Stomach. —  I  n  some  few  cases — cases  of 
hour-glass  duodenum  or  of.  duodenal  ulcer  associated 
with  a  gastric  ulcer  as  to  whose  condition  (whether 
simple  or  malignant)  some  doubt  exists — removal  of  a 
part  of  the  duodenum  may  be  necessary.  If  the  portion 
to  be  removed  is  small,  an  end-to-end  anastomosis  may 
be  practised  after  the  duodenum  has  been  "mobilised" 
according  to  the  method  of  Kocher  and  Finney.  In 
most  cases,  however,  a  closure  of  the  divided  ends  of 
the  stomach  and  duodenum,  followed  by  gastroenter- 
ostomy, will  be  necessary.  The  technical  details  are 
in  all  respects  those  to  be  observed  in  cases  of  partial 
gastrectomy,  and  no  special  discussion  of  them  here  is 
necessary. 

4.  Resection  of  the  Duodenum  Alone,  the  Pylorus 
Being  Left  Intact. — I  have  only  twice  practised  this 
operation,  which  I  think  in  certain  cases  may  prove 
to  be  useful.  The  excision  of  a  cylinder  of  the  duo- 
denum is  preceded  by  the  separation  of  the  omenta 
on  the  upper  and  lower  borders  after  ligature.  Each 
end  of  the  segment  to  be  removed  is  then  seized  with  a 
clamp,  the  intervening  ulcer-bearing  portion  excised, 
and  the  distal  end  closed  by  suture.  The  second  por- 
tion of  the  duodenum  is  then  lifted  away  from  the 
hinder  wall  of  the  abdomen,  and  a  clamp  applied  verti- 
cally to  it.  Then  the  proximal  cut  end  of  the  duodenum 
is  united  l>\  suture  to  an  incision  in  the  clamped  second 
part  of  the  bowels.      In   the  first  case  in  which   I   per- 


The  Treatment  of  Chronic  Duodenal  Ulcer    195 

formed  this  operation  I  made  the  anastomotic  opening 
too  small,  and  I  therefore  performed  gastroenterostomy 
immediately.  The  second  case  has  been  done  very  well. 
It  is  possibly  an  advantage  to  leave  intact  the  pyloric 
valve,  whose  exquisite  mechanism  has  been  described 
by  Pawlow. 


CHAPTER  IX 
JEJUNAL  AND  GASTRO-JEJUNAL  ULCER 

Now  that  we  have  arrived  at  a  stage  in  the  develop- 
ment of  the  surgery  of  the  simple  diseases  of  the  stomach 
and  duodenum  in  which  we  are  entitled  to  say  that 
many  of  the  technical  difficulties  have  disappeared, 
and  that  almost  all  our  anxiety  as  to  the  immediate 
result  of  an  operation  has  long  been  allayed,  we  are 
chiefly  concerned  to  discover  the  remote  destiny  of 
our  patients.  Enquiry  assures  us  that  when  gastro- 
enterostomy is  now  performed  in  suitable  cases,  the 
immediate  mortality  is  very  low,  certainly  less  than 
2  per  cent.,  and  the  ultimate  condition  of  the  very  great 
majority  of  the  patients  most  satisfactory.  In  con- 
nexion with  the  operation  there  remains  only  one 
serious  complication  to  be  faced,  that  is,  the  develop- 
ment of  a  new  ulcer  in  or  near  the  site  of  the  anastomosis 
made  between  the  stomach  and  the  jejunum.  Of  the 
history  of  this  condition  of  jejunal  or  gastro-jejunal 
ulcer,  since  its  first  recognition  by  Braun  in  1899,  it  is 
nut  necessary  to  speak  here.  A  very  full  account  is 
given  in  several  recent  articles,  the  most  notable  of 
which  is  by  Van  Roojen  ("Arch.  f.  klin.  Chir.,"  1910, 
xci,  380);  see  also  Paterson •  (" Proc.  Roy.  Soc.  Med.," 
June,  1909,  and  separate  publication),  Wilkie  ("Ed. 
Med.  Jour.,"  1910).  Van  Roojen  gives  brief  details 
of  89  cases,  and  to  these  three  recorded  by  Wilkie,  two 

196 


Jejunal  and  Gastro-jejunal  Ulcer  197 

cases  upon  which  I  have  operated,  and  cases  privately 
related  to  me  by  Rutherford  Morison,  Norman  Porritt, 
and  Basil  Hall,  and  others,  with  the  three  cases  related 
below,  bring  the  total  up  to  over  100.  It  is  remarkable 
that  so  few  cases  are  recorded  in  American  literature, 
seeing  that  the  development  of  the  surgery  of  the  stom- 
ach has  been  so  active  in  that  country.  It  is  almost 
certain  that  if  they  had  occurred  they  would  have  been 
reported. 

Ulceration  at  the  line  of  suture,  or  in  the  jejunum 
very  close  thereto,  occurs  almost  exclusively  after 
operation  for  simple  disease.  In  only  one  case  in  the 
literature  was  the  gastroenterostomy  performed  for 
carcinoma;  this  is  recorded  by  Axel  Key  out  of  the 
practice  of  Lennander  ("Nordisk.  Med.  Arkiv,"  1907, 
xl,  97).  The  patient  was  a  woman,  aged  twenty-five, 
who  had  a  tumour  of  the  pylorus  for  which  resection 
followed  by  anterior  retrocolic  gastroenterostomy  was 
performed.  The  patient  died  on  the  tenth  day  from 
peritonitis.  An  examination  of  the  specimen  proved 
the  growth  to  be  carcinomatous.  In  the  distal  limb  of 
the  jejunum  were  found  two  small  round  "perforating" 
ulcer-.  20  mm.  and  37  mm.  from  the  anastomosis.  In 
every  other  case  recorded  the  disease  was  non-malig- 
nant. The  ulcer  may  be  single,  or  there  may  be  two. 
three  or  lour  ulcer-.  Asa  rule,  the  ulcer  lie-  close  t". 
and  isexactl}  on  the  line  ol,  the  anastomosis,  but  some- 
times ii  may  be  an  inch  or  two  away  in  the  bowel,  at 
either  side  of  the  anastomosis.  In  58  cases  Van  Roojen 
found   t  he  posil  ion   to  be — 


198  Duodenal  Ulcer 

In  the  closest  proximity  to,  or  exactly  upon  the  suture  line 

in 40 

In  the  proximal  limb  of  the  jejunum  in 6 

In  the  distal  limb  of  the  jejunum  in 8 

In  or  near  the  point  of  an  entero-anastomosis 2 

The  ulceration  occurs  after  every  form  of  gastroenter- 
ostomy.    The  following  list  is  given  by  Van  Roojen: 

Anterior  gastroenterostomy 29 

Anterior  gastroenterostomy  with  entero-anastomosis 12 

Anterior  gastroenterostomy  in  "  V  " 10 

Anterior  L'.astro-enterostomy  retrocolic I 

52 

Posterior  gastroenterostomy 20 

Posterior  gastroenterostomy  with  entero-anastomosis 1 

Posterior  gastroenterostomy  in  "  Y" 3 

Posterior  gastroenterostomy  antecolic  in  "  Y" 1 

25 

It  would  appear  from  this  that  twice  as  many  cases 
of  jejunal  ulcer  have  occurred  after  the  anterior  as  have 
been  known  after  the  posterior  operation;  but  we  have 
no  knowledge  of  the  relative  frequency  of  the  adoption 
of  these  two  methods.  Van  Roojen,  in  order  to  investi- 
gate this  question  with  a  nearer  approach  to  accuracy, 
collected  the  details  of  613  cases  of  gastro-enterostomy 
in  which  10  cases  of  jejunal  ulcer  had  occurred.  There 
were  189  cases  of  anterior  gastro-enterostomy  with  6 
cases  of  jejunal  ulcer,  and  444  examples  of  the  posterior 
operation  with  4  cases  of  ulcer. 

The  time  at  which  the  ulcers  appeared  is  given  in 
the  following  table  from  Van  Roojen: 


Jejunal  and  Gastrojejunal  Ulcer  199 

Within  ten  days  in 3  cases 

Ten  days  to  three  months 5 

Three  months  to  six  months g 

Six  months  to  twelve  months 10      " 

One  year  to  one  and  one-half  years 9 

One  and  one-half  years  to  two  years 6 

Two  years  to  three  years 5 

Three  years  to  four  years 8      " 

Four  years  to  five  years 4 

Five  years  to  ten  years 6     " 

Ten  years  and  later 1  case 

66  cases 

Dr.  Norman  Porritt  has  kindly  furnished  me  with  the 
notes  of  a  case  in  which  two  perforations  occurred,  one 
in  a  jejunal  ulcer,  and  one  in  an  acute  ulcer  on  the 
lesser  curvature  of  the  stomach,  six  days  after  the 
operation  of  gastroenterostomy. 

J.  S.,  tailor,  twenty-nine,  suffering  from  pyloric  stenosis. 
Posterior  gastroenterostomy  performed  4.30  p.  m.  on  May 
7,  1906.  Did  well  until  6  A.  M.  May  13th,  when  he  had  a  slight 
abdominal  pain,  followed  by  very  severe  attack-  of  pain  at 
2  p.  m.  and  6  P.  m.,  followed  by  abdominal  distension  and 
rigidity.  Operation  May  14th,  5.30  p.  m.  The  abdomen  wa- 
re-opened through  the  original  incision.  Dark,  bilious  looking 
fluid  found  free  in  abdomen.  The  anastomosis  lay  far  to  the 
left   of  the  middle  line  sound  and  perfect.      The  jejunum  was 

freed  from  the  mesocolon,  and  in  pulling  it  up  gas  bubbled 
from  the  lesser  sac  and  then-  was  seen  a  round,  punched-out 
hole  in  the  jejunum  from  which  bilious  liquid  exuded.  The 
hole  was  of  the  diameter  of  .1  small  lead-pencil.  The  perfora- 
tion was  closed  with  a  double  row  of  Lembert's  stitching,  but 
on  account  of  the  bad  condition  of  the  patient  nothing  more 
was  done  than  a  hasty  mopping  oul  of  the  lesser  peritoneal 
.md  the  insertion  of  a  broad  glass  tube  l>>  a  stab  incision 
above  the  pubes  and  a  gauze  drain  down   to  the  perforated 


200  Duodenal  Ulcer 

ulcer.  As  soon  as  the  glass  tube  reached  the  pelvis  thick 
yellow  liquid  like  semi-digested  food  welled  from  it.  On  May 
15,  1906,  at  3  a.  m.,  the  patient  died. 

Postmortem  Examination. — There  was  no  evidence  of  old 
ulceration  in  stomach  or  jejunum,  but  the  pylorus  was  nar- 
rowed to  a  tunnel  which  would  barely  admit  a  lead-pencil.  It 
was  thickened  all  round  and  the  lump  left  at  the  operation  was 
now  very  plainly  recognised.  The  anastomosis  between  the 
stomach  and  the  jejunum  was  sound  and  good,  but  on  the 
lesser  curvature  near  the  pylorus  was  a  round,  punched-out 
perforated  ulcer.  The  ulcer  found  and  stitched  at  the  last 
operation  was  examined.  It  involved  the  wall  of  the  bowel 
farthest  from,  but  opposite  to,  the  anastomosis,  and  was  a 
simple,  punched-out,  circular,  clean-cut  hole. 

The  cause  of  the  development  of  a  jejunal  or  a  gastro- 
jejunal  ulcer  has  not  yet  been  made  clear.  It  is  probably 
not  the  same  in  all  cases.  It  may  be  the  smallness  of 
the  opening;  a  bruising  of  the  edges  of  the  anastomosis, 
or  the  development  of  a  hematoma  in  the  w^all  of  either 
viscus  as  the  result  of  the  wounding  of  a  vessel  by  a 
needle;  the  persistent  presence  of  excessive  quantities 
of  free  HC1;  or  the  tearing  and  unceasing  irritation  of 
an  unabsorbable  inner  thread  which  has  only  partly 
been  released  from  the  suture  line.  Van  Roojen  found 
that  in  only  three  cases  in  which  an  ulcer  was  found  at 
the  line  of  the  anastomosis  was  any  trace  of  thread  or 
silk  to  be  discovered.  In  a  case  of  Battle's  ("Lancet," 
1906,  pp.  274,  1246)  an  inner  suture  inserted  thirteen 
months  before  was  removed  from  the  anastomotic  line, 
but  the  jejunal  ulcer  was  an  inch  away.  Wilkie  ("Edin. 
Med.  Jour.,"  1910,  ii),  in  an  excellent  account  of  some 
experimental  work  conducted  to  elucidate  this  question, 
shews  that  the  union  of  the  mucosa  at  the  line  of  anas- 


Jejunal  and  Gastro-jejunal  Ulcer  201 

tomosis  occurs  by  granulation  in  about  seven  days,  and 
he  concludes,  on  evidence  that  is  perhaps  a  little  slender, 
that  "the  presence  of  an  unabsorbable  suture  in  the 
granulation  area  tends  to  delay  repair."  Accordingly, 
he  considers  it  advisable  to  employ  some  absorbable 
material  for  the  inner  stitch. 

It  seems  not  unlikely  that  the  occurrence  of  a  jejunal 
ulcer  may  be  due  to  a  persistence  of  those  causes  which 
first  set  at  work  the  changes  leading  to  the  development 
of  the  chronic  ulcer  for  which  the  gastroenterostomy 
was  performed.  Gastric  and  duodenal  ulcers  are  prob- 
ably always  secondary,  and  so  far  as  my  own  clinical 
observation  goes,  they  would  appear  to  be  secondary 
to  an  infection  elsewhere,  generally  within  the  abdomen, 
but  possibly  apart  from  it,  in  the  mouth,  on  the  skin, 
or  elsewhere.  Of  all  the  evident  primary  causes,  those 
within  the  alimentary  canal  are  the  commonest;  of 
these  a  diseased  condition  of  the  appendix  is  by  far 
the  most  frequent.  The  appendix  should,  therefore. 
always  be  removed  when  the  operation  of  gastro- 
enterostomy is  being  done,  and  any  other  infective 
causes  sought,  and,  if  found,  dealt  with  radically  it 
possible. 

A  search  through  the  recorded  examples  of  this  con- 
dition shews  that  four  clinical  types  ol  ulcer  can  be 
recognised : 

I.  The  ulcer  develops  rapidly  and  perforates  shortly 
alter  the  operation.  There  are  only  lour  cases  which 
can  be  included  in  thi>  group.  The  circumstance--  in 
all  are  similar:  Gastro-enterostomy  was  performed  for 
an    ulcer   at    or    beyond    the    pylorus,    associated    with 


202  Duodenal  Ulcer 

hyperacidity,  which  in  two  cases  was  intense;  the 
progress  for  the  first  few  days  was  satisfactory,  then 
suddenly  there  was  an  acute  onset  of  pain,  followed 
by  peritonitis  and  death.  In  all  cases  an  ulcer  just 
beyond  the  anastomosis  was  found,  and  perforation 
has  occurred  into  the  general  cavity. 

II.  The  ulcer  develops  within  a  few  weeks  or  months 
of  the  operation  and  the  symptoms  suggest  a  recurrence 
of  the  ulcer  for  which  the  operation  was  performed,  or 
a  stenosis  of  the  new  opening.  The  cases  in  this  group 
are  many.  The  symptoms  are  very  similar  to  those 
which  were  caused  by  the  original  ulcer  in  the  stomach 
or  in  the  duodenum,  for  which  the  gastro-enterostomy 
was  performed;  or  they  can  be  referred  to  a  mechanical 
difficulty  in  the  emptying  of  the  stomach.  These 
complaints  are  attributed  to  a  supposed  "recurrence" 
of  the  ulcer.  Secondary  operations  were  performed  for 
disabling  symptoms,  for  haemorrhage,  or  for  perforation 
and  peritonitis.  In  these  last  instances  acute  perfora- 
tion had  occurred  in  a  chronic  ulcer. 

III.  The  ulcer  develops  slowly,  and  insidiously  under- 
goes a  "subacute"  perforation,  with  the  result  that  a 
tumour  forms  in,  or  abutting  upon,  the  epigastrium. 
About  two-fifths  of  all  the  recorded  examples  fall  in  this 
category.  There  are  not  usually  any  symptoms  of 
which  the  patient  takes  serious  notice.  As  a  rule,  only 
some  trivial  discomfort  after  meals  or  "indigestion" 
is  noticed;  on  examination  of  the  patient  a  distinct 
tumour  is  felt.  When  the  abdomen  is  opened,  the 
jejunum  at  or  near  the  anastomosis  is  found  adherent, 
usually  to   the  parietes.     On  separating  the  viscera  a 


Jejunal  and  Gastro-jejunal  Ulcer  203 

perforation  into  the  intestine  at  the  site  of  an  ulcer  a 
little  below  the  anastomosis  is  discovered.  The  con- 
dition, it  will  be  seen,  is  precisely  analogous  to  that 
of  "subacute  perforation"  in  the  stomach  (see  "Annals 
of  Surgery,"  1907,  vol.  xlv,  p.  223). 

IV.  The  ulcer  perforates  into  a  hollow  viscus.  The 
ulcer  is  of  the  chronic  type,  and  perforation  occurs 
after  adhesion  to  a  hollow  viscus — either  the  stomach 
or  the  colon. 

Treatment. — The  treatment  of  a  peptic  jejunal  ulcer 
may  be  beset  with  almost  insuperable  difficulties. 
Much  will,  of  course,  depend  upon  the  conditions  found 
at  the  time  of  the  operation.  If  an  acute  perforating 
ulcer  be  found,  it  will  probably  be  enough  in  many  cases 
to  close  the  ulcer  by  sutures  and  by  subsequent  careful 
dieting  and  rest  to  avoid  the  recurrence  of  trouble 
In  the  cases  where  the  ulcer  is  of  the  chronic  type,  and 
especially  in  those  wherein  a  subacute  perforation  has 
occurred,  a  resection  of  the  jejunal  length  engaged  in  the 
anastomosis  and  of  the  adjacent  part  of  the  stomach, 
followed  by  the  making  of  a  new  junction  between  the 
stomach  and  the  jejunum  at  a  slightly  lower  level,  will 
be  needed.  If  the  original  anastomosis  has  been  of  the 
posterior  no-loop  variety,  then  the  performance  of  a 
ction  of  the  -anastomosis  i-  exceedingly  difficult, 
.1-  I  have  good  reason  to  know.  In  such  a  case  ii  is 
belter  to  cut  the  jejunum  across  immediately  above 
it^  attachmenl  to  the  stomach,  and  alter  resection  ol 
the  anastomosis   to   make   the   new    junction   ,A\cv   the 

"Y"     method    of     RoUX         It     tile    ulcer    should     be    at     or 

near  tin-  anastomosis,  and  a  resection  oi  the  kind  just 


204  Duodenal  Ulcer 

mentioned  be  impossible,  then  I  would  suggest  the 
free  opening  of  the  stomach  by  an  incision  along  the 
anterior  surface,  in  order  that  access  may  be  gained  to 
the  ulcer  from  the  gastric  side.  Probably  then  the  anas- 
tomosis could  be  pushed  from  behind  through  the 
wound  in  the  anterior  wall  of  the  stomach  and  a  resee- 
tion  of  the  ulcer  performed.  This  method  I  have  sev- 
eral times  adopted  for  the  suture  or  excision  of  ulcers, 
apparently  otherwise  inaccessible,  on  the  posterior  wall 
of  the  stomach  adherent  to  the  pancreas.  The  operation 
may  be  called  "  transgastric  resection  or  suture  of  an 
ulcer." 

The  following  three  cases  of  jejunal  ulcer  treated 
by  operation  have  been  under  my  care.  The  original 
gastroenterostomy  in  cases  I  and  3  was  performed  by 
other  surgeons;  in  Case  2,  by  myself.  In  none  of  the 
eases  was  any  trace  of  the  original  inner  suture  discovered. 
Case  1  is  remarkable  for  the  fact  that  two  operations 
for  the  excision  of  jejunal  ulcers  were  conducted  within 
a  period  of  seven  months. 

Case  i. — Old  perforated  duodenal  ulcer.  Posterior  gastro- 
enterostomy. Recurrence  of  duodenal  ulcer.  Jejunal  ulcer. 
Excision  of  anastomosis.     Modified  Roux's  operation 

M.,  Major  R.  A.  M.  C,  aged  forty-two.  In  1892  whilst 
abroad  had  an  illness,  associated  with  acute  pain  over  gall- 
bladder region,  pyrexia  and  nocturnal  delirium,  which  was 
diagnosed  as  enteric  fever;  he  was  invalided  to  Malta,  where 
he  contracted  Malta  fever.  After  return  home  attacks  of 
acute  pain  in  gall-bladder  region  kept  recurring  and  were  ac- 
companied by  vomiting.  During  the  war  in  South  Africa 
was  well,  but  on  way  home  he  woke  suddenly  one  night  with  a 
very  sudden  and  acute  attack  of  pain,  which  did  not  com- 
pletely cease  for  three  weeks.      During  none  of  these  attacks 


Jejunal  and  Gastro-jejunal  Ulcer  205 


H 


2o6 


Duodenal  Ulcer 


did  he  have  jaundice,  hsematemesis,  or  melsena.  During  the 
next  two  years  the  attacks  of  pain  kept  recurring;  pain  nearly 
always  occurred  two  or  three  hours  after  food.  A  diagnosis  of 
gall-stones  was  made,  and  operation  arranged  for  in  April, 
1902.  Five  days  before  date  fixed  for  operation  a  sudden  at- 
tack of  most  excruciating  pain  in  the  upper  abdomen,  which 
persisted  until  the  operation  was  performed.     The  condition 


lac.  54. — Cask   i. 

The  parts  removed  at  the  second  operation.     An  ulcer  which  was  mi  the 

verge  of  perforation  is  seen. 


then  found  was  a  perforated  duodenal  ulcer  evidently  on  the 
upper  and  posterior  wall,  with  considerable  localised  peri- 
tonitis. The  perforation  was  closed  and  the  gall-bladder 
drained,  although  so  far  as  can  be  learned  no  gall-stones  wen- 
found. 

I  Hiring  the  six  months  following  operation  he  had  no  trouble, 
but  then  he  began  to  have  a  return  of  the  pain,  although  it  was 


Jejunal  and  Gastro-jejunal  Ulcer  207 

not  quite  so  definite  in  its  onset  after  food  as  before  his  first 
operation.     There  was  no  vomiting. 

In  May,  1903,  posterior  gastroenterostomy  was  performed 
by  the  same  surgeon  in  London  For  six  to  eight  months  he 
was  subject  to  attacks  of  biliary  vomiting;  these  then  ceased, 
but  pain  began  to  recur  and  lasted  for  three  to  four  weeks; 
usually  it  was  relieved  by  a  milk  diet. 

In  1904  pain  was  very  severe,  and  a  diagnosis  of  jejunal 
ulcer  was  made;  he  was  put  on  fluid  diet  for  months,  with 
relief.  During  1906  and  1907  was  much  better  and  had  only 
one  or  two  attacks,  which  occurred  after  playing  golf. 

In  July,  1908,  passed  a  very  tarry  motion  but  had  no  pain, 
In  September  a  much  worse  attack,  with  acute  pain  situated 
midway  between  umbilicus  and  left  costal  margin.  He  was 
in  a  Nursing  Home  under  treatment  with  antilytic  serum, 
which  appeared  to  relieve  the  pain  temporarily.  On  December 
8th  he  woke  at  4  A.  m.  with  a  feeling  of  oppression  in  stomach, 
followed  by  vomiting  of  between  three  and  four  pints  of  blood; 
mehena  for  several  days  after.  Since  that  time  has  had  saurin 
treatment,  etc.,  but  the  pain  has  kept  recurring,  most  fre- 
quently at  2  a.  M. 

When  seen  by  me  in  March,  1909,  I  made  the  following 
diagnosis:  Duodenal  ulcer,  possibly  jejunal  ulcer.  Patent 
pylorus,  partial  closure  of  anastomotic  opening. 

Operation  was  performed  on  March  24,  1909.  Incision 
just  to  right  of  middle  line,  close  to  old  incision.  The  gall- 
bladder margin  of  liver  and  stomach  were  found  to  be  involved 
in  a  mass  of  tough  adhesions  which  wire  separated  with  much 
difficulty;  the  omentum  and  transverse  colon  were  turned  up 
over  the  anterior  aspect  of  the  stomach  and  were  adherenl  10 
1  he  anterior  abdominal  wall. 

The  parts  were  defined,  and  it  was  found  that  a  large  in- 
durated scar  was  presenl  in  the  anterior  wall  of  the  first  ran 
of  the  duodenum. 

The  gastro-enterostomy  was  next  examined,  ami  it  was 
found  that  the  opening  was  patent,  but  the  two  limbs  ol  the 
jejunum  were  almost  parallel  up  to  the  anastomosis;  a  con- 
siderable "loop"  was  present.  Alter  the  firm  surrounding 
adhesions  had  been  separated,  the  anastomosis  was  carefull) 


208  Duodenal  Ulcer 

palpated,  an  indurated  "knot"  was  felt  on  the  mesenteric 
aspect  ot  the  gu.1  jusl  opposite  the  gastro-enterostomy  open- 
ing. This  was  thought  to  indicate  a  jejunal  ulcer,  so  it  was 
decided  to  excise  the  anastomosis.  The  two  limbs  were 
clamped  and  divided,  and  the  stomach  incised  with  scissors 
just  around  the  anastomotic  opening. 

The  end  of  the  efferent  limb  was  next  closed  by  suture,  and 
a  lateral  anastomosis  performed  between  it  and  the  opening 
already  existing  in  the  stomach.  The  proximal  limb  was 
next  implanted  into  the  distal  by  an  end-to-side  anastomotic. 
The  raw  surface  left  by  the  ligation  of  the  mesentery  was 
covered  in  as  completely  as  possible.  Duodenal  ulcer  and 
pylorus  infolded  by  several  sutures.  Abdomen  closed.  The 
operation  was  extremely  difficult  throughout  and  took  two 
and  one-half  hours. 

October,  1909.  Since  operation  he  has  not  been  any  better, 
but  his  pain  has  been  constant  both  night  and  day,  though 
varying  much  in  intensity.  For  example,  he  had  always  more 
when  he  took  any  exercise.  His  pain  was  localised  to  a  small 
area,  just  to  the  left  of  the  umbilicus,  and  here  he  thought  he 
could  feel  a  lump,  but  no  one  else  has  made  this  out.  He  finds 
food  of  any  sort  sets  the  pain  going  in  a  few  minutes.  The 
pain  is  a  constant  hot  sensation  which  never  actually  leaves 
him.  and  which  is  particularly  bad  at  night.  He  has  been 
having  small  doses  of  morphia  at  nights  since  the  last  operation 
in  June.  He  has  tried  olive  oil  treatment  without  benefit; 
t  he  only  things  that  relieve  him  are  strong  alkalis  and  morphia. 
He  has  lost  a  considerable  amount  of  weight  ot  late. 

Further  operation,  October  7,  1909.  Incision  through  right 
rectus  in  one  of  the  old  scars;  a  very  firm  mass  ot  adhesions  was 
met  with  and  much  time  spent  in  separating  them;  at  length 
the  site  of  the  last  operation  was  exposed,  the  Y-shaped  junc- 
tion of  jejunum  being  found  in  good  order.  The  transverse 
colon  was  now  turned  up  and  the  posterior  gastro-enterostomy 
exposed,  the  lesser  sac  having  been  opened  and  numerous 
adhesions  having  been  separated.  On  palpation  a  hard  mass 
could  be  felt  in  the  posterior  part  of  the  line  of  suture,  with  a 
crater  in  its  centre,  and  the  whole  ma>s  being  the  si/e  of  a 
shilling.     It   was  decided  to  detach   this  gastro-enterostomy 


Jejunal  and  Gastro-jejunal  Ulcer  209 

and  remove  the  loop  of  small  intestine  down  to  the  "  Y  "-shaped 
junction,  and  to  do  a  new  anterior  gastroenterostomy.  The 
stomach  was  closed  by  two  rows  of  interrupted  Pagenstecher 
stitches. 

The  "Y-shaped  junction  was  detached  and  the  lower  seg- 
ment closed  so  as  to  reproduce  the  normal  line  of  bowel.  The 
stomach  and  transverse  colon  were  turned  up  and  the  jejunum 
followed  up  to  its  union  with  the  stomach,  and  with  some 
difficulty  the  line  of  union  was  defined.  In  separating  the 
numerous  adhesions  the  jejunal  ulcer  which  had  been  felt  on 
the  posterior  surface  of  the  anastomosis  ruptured  at  the  bot- 
tom of  its  crater,  where  it  was  extremely  thin.  The  anastomo- 
sis was  detached  with  a  collar  of  stomach  wall,  and  several 
blackened  Pagenstecher  sutures  of  the  Jast  operation  were 
found,  mostly  in  the  lumen  of  the  bowel,  attached  by  one  end 
to  the  wall.  The  hole  in  the  lesser  sac  was  closed  by  the  por- 
tion of  mesentery  belonging  to  that  portion  of  jejunum  leading 
from  the  old  gastroenterostomy  to  the  "Y "-shaped  junction; 
this  portion  of  the  gut  was  now  removed.  A  new  anterior 
gastroenterostomy  was  now  performed  in  the  usual  way,  with 
as  short  a  loop  as  possible. 

Case  2. — Duodenal  ulcer.  Ulcer  sutured.  Posterior  gas- 
troenterostomy. Appendicectomy.  Jejunal  ulcer.  Exci- 
sion. Mrs.  S.  Sent  by  Dr.  Edgecombe,  Harrogate.  Ad- 
mitted to  Nursing  Home  November  28,  1910.  All  her  life 
she  has  had  "indigestion,"  worse  of  late  years.  She  says  it  is 
an  aching  pain,  coming  on,  as  a  rule,  two  hours  after  food;  it 
comes  on  in  attacks  lasting  some  days  or  weeks;  after  a  few 
days  in  each  attack  the  pain  comes  irrespective  of  the  taking 
of  food,  but  then  food  relieves  it.  She  practically  never 
vomits.  Tin-  attacks  have  become  worse  of  late,  but  she  had 
an  attack  in  November,  1909,  and  not  another  until  a  few 
weeks  ago,  though  in  between  there  i-  some  trouble  of  a  much 
slighter  type.  The  pain  is  always  worse  in  winter,  and  i^ 
situated  invariably  above  and  to  the  left  of  the  umbilicus,  the 
area  hen-  being  very  tender.  She  has  not  had  haematemesis 
or  melaena  or  jaundice, and  had  nol  losl  weighl  excepl  in  the 
attacks,  gaining  it  at  once  in  the  quiescenl  intervals. 

November  30,  [910.  Incision  through  right  rectus.  Very 
14 


210  Duodenal  Ulcer 

well-marked  duodenal  ulcer  one-half  inch  beyond  pylorus  at 
upper  margin,  causing  marked  thickening  and  puckering  of 
duodenum.  Stomach  slightly  dilated.  Posterior  gastroen- 
terostomy performed  and  ulcer  infolded.  Appendix  was  much 
adherent,  extremely  small  and  fibrous;   it  was  removed. 

Re-admission  May  13,  191 1.  Was  operated  upon  for  duo- 
denal ulcer  and  chronic  appendicitis  November  30,  1910.  For 
a  time  she  had  relief,  but  soon  her  symptoms  began  again  "as 
bad  as  ever"  and  of  the  same  type,  but  the  pain  was  felt  lower 


I 


Fig.  55.— Case  3. 

The   parts  removed.     The  gastro-enterostomy  opening  looks  downward 

and  to  the  right.     The  ulcer  is  just  seen  within  the  upper  opening. 

down  in  the  abdomen,  and  referred  to  the  umbilicus.  Pain 
one  or  two  hours  after  food  and  relieved  by  food ;  occasionally 
pain  to  the  right  of  the  middle  line. 

Operation  May  15,  191 1.  Incision  through  old  scar.  At 
the  lowest  part  of  the  anastomosis  was  a  hard  white  indurated 
mass  involving  the  transverse  colon,  with  a  crater  on  it,  felt 
through  anterior  wall  of  stomach,  about  one  inch  long  and  one- 
half  inch  to  three-quarters  of  an  inch  broad,  the  whole  being 
plastered  down  by  adhesions.  After  separation,  the  crater's 
base  was  seen  to  be  formed  by  transverse  colon,  and  transverse 


Jejunal  and  Gastro-jejunal  Ulcer 


211 


mesocolon;  the  edges  were  in  the  line  of  the  lowest  point  of 
the  anastomosis  between  the  stomach  and  the  jejunum  and 
involve  both  organs.     The  whole  ulcerated  area  was  cut  away. 


Ulcer 


Lower  limb  of 
jejunum 


Stomach  covered 
by  transverse 
mesocolon 


^\j       Duodeno-jejuna! 
'Ikt  flexure 


Fig.  56. — Operation    for    Excision    of    the    Parts    in    a    Cask    of 
Jejunal   Ulcer.     Step  1.      (Drawn  by  Mr.  L.  R.  Braithwaite.) 


Fig.  57.  Operation  fob  Excision  01  the  Parts  in  a  Case  01 
Jeji  nal  I  it  br.  Step  2. 
The  transverse  mescx  olon  is  detached  from  the  stomach,  so  as  to  allow 
the  Btomach  to  be  drawn  well  through  the  opening.  A.  clamp  is  then  applied 
in  the  same  position  which  it  occupied  al  the  original  operation.  Clamps 
an  applied  to  the  jejunum  on  each  side  of  the  anastomosis.  (Drawn  l>v 
Mr.  L.  R.  Braithwaite.) 

The  gap  in  the  anastomosis  line  was  stitched  up  by  .1  rov  of 
interrupted  catgul  stitches  and  one  continuous  outer  suture 
hi  Pagenstecher  thread.     A  wide  opening  free  from  induration 


212 


Duodenal  Ulcer 


was  left  and  admitted  two  fingers  easily.  In  September,  191 1 , 
the  patient  wrote  to  say  that  she  was  free  from  pain,  but  acting 
under  my  instructions  was  living  on  a  spare  dietary,  consisting 
chiefly  of  liquids.' 

Case  3. — Jejunal  ulcer  following  gastro-enterostomy.  Ex- 
cision. Roux's  operation.  Appendicectomy.  Mrs.  S.  Sent 
by  Dr.  Bingham,  Lancaster.  Three  years  ago  she  had  gastro- 
enterostomy done  by  a  London  surgeon  for  duodenal  ulcer. 


Fig.  58. — Operation  for  Excision  of  the  Parts  in  a  Case  of 
Jejunal  Ulcer.  Step  3. 
The  parts  engaged  in  the  anastomosis  with  the  ulcer  are  removed.  The 
distal  end  of  the  jejunum  is  closed.  The  proximal  end  is  open  and  is  ready 
for  union  with  the  jejunum  lower  down  in  an  end-to-side  anastomosis. 
(Drawn  by  Mr.  L.  R.  Braithwaite.) 


For  some  months  she  wras  better,  then  began  to  have  pains  in 
the  body  soon  after  food — almost  immediately  after  swallowing 
it.  She  began  to  diet  herself  at  once,  and  has  done  so  ever 
since.  Nineteen  months  ago  she  had  a  very  severe  haemat- 
emesis  and  nearly  died,  and  twice  since  has  had  severe  haemat- 
emesis.  The  pain,  whenever  she  fails  to  take  great  care  in 
her  diet,  comes  on  at  a  spot  about  one  inch  above  the  umbilicus, 
and  may  be  very  severe.  She  says  it  is  like  the  pain  she  had 
before  the  operation.     She  has  not  lost  weight,  but  has  care- 


Jejunal  and  Gastro-jejunal  Ulcer  213 


> 


Fig.    59. — Operation    for    Excision    of    the    Parts    in    a    Case    of 
Jejunal  Ulcer.     Step  4. 
The   jejunal   end-to-side   anastomosis   completed.     The    upper   closed 
jejunal    end    is  now  brought   upward   for  a  side-to-side  union  with  the 
stomach.     (Drawn  by  Mr.  L.  R.  Braithwaite.) 


Fig.   60.    Operation    fob    Excision    01    the    Parts    in    \    Casi     01 

J  1   M    n  \l.    I  1LCER.      Step  5. 

I  he  operation  completed.     (Drawn  by  Mr.  L.  R.  Braithwaii 


214  Duodenal  Ulcer 

fully  dieted  herself  the  whole  time.  X-ray  examination  showed 
all  food  going  through  anastomosis. 

September  n,  191 1.  Old  scar  excised  in  right  rectus. 
Gastro-enterostomy  explored :  it  was  posterior  and  nearly 
vertical.  In  the  jejunum,  one-half  inch  below  the  beginning 
of  the  anastomosis  and  near  the  mesenteric  edge  of  it,  was  a 
small  indurated  stellate  scar,  which  was  about  the  size  of  a 
three-penny  piece,  and  by  its  contraction  caused  marked 
narrowing  of  the  jejunum.  This  was  clearly  the  scar  of  a 
jejunal  ulcer.  Owing  to  the  fact  that  a  local  incision  would 
endanger  the  vascularity  of  the  jejunum  at  this  part,  full  ex- 
cision was  performed.  The  lesser  sac  was  opened  around  the 
anastomosis  so  that  a  part  of  the  stomach  was  drawn  through 
and  a  clamp  put  on  above  the  anastomosis.  The  jejunum 
distal  to  the  anastomosis  was  clamped  and  divided  and  the 
distal  end  closed  by  suture.  The  jejunum  proximal  to  the 
anastomosis  and  to  the  ulcer  was  divided,  and,  owing  to  there 
being  a  longish  loop,  this  was  easier  than  usual,  though  even 
now  there  was  difficulty.  The  proximal  cut  end  was  anasto- 
mosed at  right  angles  to  the  distal  jejunum,  about  six  inches 
below  its  cut-and-closed  end.  The  part  of  the  jejunum  left 
attached  to  the  stomach  (including  the  ulcer),  together  with 
the  portion  of  the  stomach  projecting  beyond  the  clamp,  in- 
cluding therefore  the  gastro-enterostomy  opening,  was  excised. 

The  length  of  jejunum  formerly  distal  to  the  anastomosis, 
whose  cut  end  had  already  been  closed,  was  now  clamped,  and 
a  side-to-side  union  effected  between  it  and  the  opening,  in  the 
stomach  embraced  by  the  clamp.  The  appendix  was  adherent 
and  was  removed.  The  original  duodenal  ulcer  was  well 
marked  and  was  infolded  and  covered  in  by  omentum. 


CHAPTER  X 
PERFORATION 

Perforation  is  the  most  serious  of  the  complica- 
tions which  can  affect  a  duodenal  ulcer.  When  it  oc- 
curs, the  patient's  life  is  in  great  jeopardy,  and  recourse 
to  early  surgical  treatment  can  alone  offer  any  hope  of 
recovery.  It  is  true  that  in  some  cases  life  may  be  pro- 
longed for  some  weeks  or  even  months;  but  such  cases 
are  so  infrequent  as  to  form  a  negligible  proportion  of 
the  total  number,  and  they  are  not  to  be  looked  upon  as 
offering  any  support  to  the  view  that  by  medical  treat- 
ment alone  the  life  of  any  patient  can  be  saved.  Per- 
foration may  occur  in  an  acute  ulcer  or  in  a  chronic 
ulcer,  and  at  the  extremes  of  life.  The  youngest  example 
is  recorded  by  Cecil  Finny  ("Lancet,"  1908,  ii,  1748): 
it  occurred  in  a  child  two  months  old.  The  oldest 
patient  I  have  seen  was  a  woman  aged  seventy-seven, 
who  died  without  operation.  The  ulcer  in  the  former 
case  was  "acute";  in  the  latter,  symptoms  had  been 
presenl  lor  fori y  years. 

ACUTE  ULCER 

The  perforation  of  an  acute  ulcer,  the  type  of  ulcer 
occurring  in  cases  of  burn-,  in  septicaemia,  typhoid 
fever,  etc.,  is  of  little  clinical  importance.     In  the  greal 

majority    of    the    recorded    cases,    as    a    reference    to    the 

literature  will   shew,   the  perforation  has  produced,  in 


216  Duodenal  Ulcer 

patients  already  enfeebled  by  a  serious  disease,  so  great 
a  prostration  or  collapse  that  a  diagnosis  does  not  seem 
to  have  been  made,  and  accordingly  no  attempt  to  deal 
surgically  with  the  condition  has  been  suggested.  The 
rarity  of  the  acute  duodenal  ulcer,  its  occurrence  in 
people  who  are  already  gravely  ill  from  other  causes, 
and  the  consequent  lack  of  any  abrupt  transition  from 
health  to  desperate  illness,  account  for  the  absence  of 
timely  recognition  of  the  catastrophe.  There  is  no 
reason  why,  given  such  recognition,  an  operation  should 
not  be  adopted,  with  a  fair  chance  of  success. 

From  time  to  time  there  is  recorded,  among  a  series 
of  cases  of  perforated  duodenal  ulcer  treated  by  oper- 
ation, an  example  of  rupture  occurring  in  a  patient  in 
good  health  who  has  never  previously  exhibited  any 
symptoms  of  dyspepsia.  Such  instances  must  be  very 
rare,  for  in  over  50  cases  of  perforation  of  the  stomach 
or  duodenum  upon  which  I  have  operated  I  have  only 
once  met  with  an  irrefutable  example,  the  ulcer  being 
in  the  stomach.  Mitchell,  Caird,  Miles,  and  others, 
however,  have  reported  one  or  more  cases  of  the  kind, 
so  that  of  their  existence  there  can  be  no  question. 
Their  diagnosis  and  their  treatment  are  in  no  way  dif- 
ferent from  those  of  the  chronic  ulcer. 

CHRONIC  ULCER 
It  is  commonly  the  chronic  form  of  duodenal  ulcer 
which  perforates.  Though  the  perforation  is  "acute," 
the  ulcer  in  which  the  perforation  occurs  is  "chronic." 
In  my  own  series  of  11  cases  there  has  not  been  a  single 
instance  of  an  acute  ulcer  perforating;    in  all  cases  the 


Perforation  217 

evidence  that  the  ulcer  had  long  been  present  was 
undeniable.  Moreover,  the  ulcer  would  seem  to  have 
been  recently  the  seat  of  more  active  pathological 
changes  than  were  customary:  for  in  almost  every 
instance  it  had  given  not  only  sustained  evidence  of  its 
presence,  but  had  been  responsible  for  a  very  distinct 
exacerbation  in  the  severity  of  the  symptoms  for  days 
or  weeks  before.  The  perforation  occurs,  then,  as  a 
rule,  with  few  exceptions,  in  a  chronic  ulcer,  whose 
symptoms  have  repeatedly  excited  attention,  and  whose 
increased  activity  has  been  announced  by  the  more 
marked  intensity  of  those  symptoms  in  the  recent  days. 
The  warning  is  given,  but  is  consistently  unheeded. 
This  fact,  to  which  I  have  repeatedly  drawn  attention, 
is  of  the  greatest  importance,  for  it  means  that  with  care 
and  timely  help  the  perforation  of  an  ulcer  can  be  pre- 
vented, or  at  least  rendered  less  likely.  In  a  few  cases, 
including  two  of  my  own,  the  catastrophe  occurred 
when  the  patients  were  in  bed  awaiting  the  performance 
of  gastro-enterostomy  which  had  been  arranged  for  the 
same  day.  It  is  possible  that  the  straining  caused  by 
the  use  of  the  -tomach-tube  has  a  harmful  effect.  I  am 
well  aware  of  the  fact  that  rases  are  recorded  by  various 
observers  in  which  it  is  said  that  no  previous  symptoms 
have  been  present,  the  patients  having  taken  ordinary 
diet,  without  pain  or  discomfort,  up  to  the  moment 
when  symptoms  abruptly  appeared.  Cases  are  also 
recorded  by  Miles  ("Edin.  Med.  Journ.,"  [906,  ii,  1  <  >o 
and  others  in  which  patients  who  had  previously  suffered 
from  indigestion  had  been  tree  from  symptoms  for  .1 
"considerable  period"  prior  to  the  occurrence  <>t   per- 


2i8  Duodenal  Ulcer 

foration.  Before  such  evidence  is  accepted,  however, 
we  must  have  fuller  details  of  the  history,  for  patients 
who  at  first  deny  the  existence  of  symptoms  will  generally 
acknowledge  that  they  have  had  "indigestion"  so  long 
as  to  have  ceased  to  remark  upon  it;  it  has  been  a  part 
of  their  daily  condition,  to  which  they  submit  uncom- 
plainingly. The  best  authenticated  case  of  perforation 
without  antecedent  symptoms  is  given  by  A.  B.  Mitchell, 
who  writes: 

"A  publican,  aged  forty-three,  steadfastly  maintained,  in 
face  of  the  strictest  cross-examination,  that  up  to  the  moment 
of  perforation,  on  2ist  July,  1907,  he  never  had  any  discomfort 
whatsoever.  He  was  shewn  by  me  at  a  meeting  of  the  Ulster 
Medical  Society  on  5th  March,  1908,  when  he  stated  that  he 
had  remained  in  excellent  health  since  the  operation,  seven 
and  a  half  months  previously.  Four  days  later,  however, 
he  again  perforated  without  any  premonitory  symptom.  He 
had  been  drinking  freely,  and  after  operation  developed  some 
incipient  sign  of  delirium  tremens.  On  this  occasion  gastro- 
jejunostomy was  combined  with  closure  of  the  perforation, 
with  successful  result." 

This  man  had  been  a  "steady  drinker" — -a  fact  which 
may  account  for  the  latency  of  his  symptoms. 

The  immediate  cause  of  the  perforation  is  not  easy  to 
discover.  In  not  a  few  cases  some  definite  disturbance 
is  held  responsible,  such  as  a  blow  on  the  side,  over- 
reaching, a  sudden  twist,  or  coughing  or  sneezing.  In 
one  of  my  own  cases  the  patient  was  crushed  by  a  heavy 
barrel  which  ran  across  the  abdomen  (Case  8).  In 
another  case  the  distension  of  the  upper  part  of  the 
jejunum  and  of  the  duodenum,  by  reason  of  the  obstruc- 
tion of  the  jejunum  in  a  right  duodenal  hernia,  seemed 


Perforation  219 

to  have  burst  what  was  doubtless  already  a  weak  spot 
in  the  bowel  wall  (Case  10).  In  some  cases  a  heavy 
meal  an  hour  or  two  before  is  held  culpable.  In  most 
of  the  cases,  however,  no  definite  causative  factor  can 
be  ascertained. 

In  describing  the  symptoms  attendant  upon  the  per- 
foration of  a  duodenal  ulcer  I  wish  to  draw  a  very  neces- 
sary distinction  between  those  which  are  due  to  the 
perforation  itself,  and  those  which  are  due  to  the  condi- 
tions which  are  aroused,  secondarily,  by  the  perforation. 
The  descriptions  which  are  usually  given  of  the  symp- 
toms following  upon  the  perforation  are,  in  fact,  com- 
plications which  early  treatment  could  prevent. 

When  perforation  occurs,  there  is  a  sudden  onset  of 
the  most  intolerable,  agonising  pain.  The  pain  is 
hardly  exceeded  in  severity  by  any  that  a  human  being 
can  suffer;  the  extremity  of  agony  is  reached.  So 
profound  may  the  instant  impression  be,  that  death 
results.  Some  of  the  so-called  "sudden  deaths"  arc 
due  to  this  form  of  perforation.  I  recorded  such  a  case 
myself  ("Lancet,"  1901,  ii,  1656),  and  specimen  806 
in  St.  Mary's  Hospital  Museum,  which  shews  a  perfor- 
ation of  a  chronic  ulcer  in  the  first  part  of  the  duodenum, 
was  taken  from  the  body  of  an  Oxford  professor,  who 
fell  down  and  died  in  the  street  iii  London.  The  patient 
is  always  prostrate  with  agony;  h<'  looks  pale  and  faint, 
his  face  wears  a  deeply  anxious  expression,  the  eyes  are 
wide  and  watchful,  bead--  of  sweat  stand  out  upon  the 
brow,  and  lines  arc  quickly  graven  on  the  checks.  The 
patient  breathes  shortly  and  quickly;  he  cannot  take 
a  deep  inspiration    the  attempt  to  do  so  end-  in  .1  groan 


220  Duodenal  Ulcer 

or  shout  of  agony  and  a  spasm  of  pain.  The  answers 
to  one's  questions  are  given  in  snatches,  and  every 
expiratory  phase  ends  abruptly  in  a  catch.  Collapse 
is  certainly  not  present,  however,  when  the  patient  is 
seen  within  an  hour  or  two,  if  it  is  to  be  measured  by  the 
ordinary  signs,  for  the  pulse  is  not  rapid, — it  is  usually 
not  more  than  80, — and  its  quality  is  not  much  impaired. 
The  surface  of  the  body  is  perhaps  a  little  cold,  though 
not  generally  so,  at  first.  Any  examination  of  the  abdo- 
men is  resented.  It  will  be  found  that  the  abdominal 
wall  is  tight;  it  is  held  with  a  rigidity  that  never  for 
one  instant  slackens.  The  abdomen  is  retracted,  never 
at  this  stage  distended ;  that  comes  later.  The  extreme 
tenseness  of  all  the  abdominal  muscles  cannot  be  induced 
to  relax  by  any  change  of  posture;  the  protective 
muscular  splint  is  never  removed ;  the  muscles  are  never 
off  their  guard.  When  it  is  remembered  that  the 
diaphragm  is  also  an  abdominal  muscle,  the  shallow 
respiration  is  at  once  understood.  A  careful  examina- 
tion of  the  abdomen  will,  I  believe,  always  (though  I 
cannot  assert  it  positively)  reveal  an  area  of  more 
exquisite  tenderness,  and  if  possible  of  even  more 
obdurate  resistance,  than  the  rest.  This  area  will  be 
found  to  the  right  of  the  mid-line  and  above  the  umbilicus. 
In  cases  of  gastric  perforation  the  area  varies,  in  my 
experience,  according  to  the  position  of  the  ulcer. 
Vomiting  may  occur  at  the  first,  but  usually  does  not; 
doubtless  its  presence  depends  upon  the  state  of  reple- 
tion of  the  stomach.  I  find  that  it  was  observed  in 
about  25  per  cent,  of  the  recorded  cases;  it  is  accord- 
ingly of  no  value  as  a  diagnostic  sign.     The  liver  dull- 


Perforation  221 

ness  is  not  impaired,  but  percussion  of  the  liver,  or 
indeed  of  any  part  of  the  abdomen,  is  deeply  resented 
by  the  patient.  The  symptoms  I  have  described  are 
those  due  to  the  perforation,  to  the  sudden  onset  of  the 
rupture  in  the  ulcer:  they  are  ample  to  permit  of  an 
assured  diagnosis  of  some  perforation,  and  of  a  probable 
diagnosis  of  duodenal  perforation,  being  made.  By 
degrees,  however,  and  as  a  rule  speedily,  the  symptoms 
alter,  as  pathological  changes  are  set  going  by  the  escape 
of  fluid  through  the  opening  at  the  base  of  the  ulcer. 
The  chief  of  these,  and  the  most  significant,  is  the  steady, 
uninterrupted  rise  in  the  pulse-rate.  As  the  frequency 
increases,  the  quality  becomes  poorer.  If  observed 
from  hour  to  hour,  the  change  is  always  for  the  worse, 
unless  morphine  be  given,  when  a  temporary  betterment 
is  noticed.  The  abdomen,  though  it  never,  or  only  at 
the  last,  when  there  is  profound  toxaemia,  loses  its 
rigidity,  becomes  fuller,  until  a  uniform  and  tight  disten- 
sion is  found.  Tenderness  becomes  more  marked  on 
the  right  side  in  almost  every  instance,  and  the  right 
iliac  fossa  may  come  to  be  the  most  exquisitely  tender, 
and  on  palpation  the  fullest,  region  of  the  belly.  The 
temperature,  which  at  first  had  been  normal  or  even 
subnormal,  rises  a  little,  and  may  attain  a  height  of  1010 
or  even  more.  The  breathless  condition  persists,  and 
increases  as  the  abdomen  fills.  A  livid  colour  comes 
over  the  face;  the  face  and  the  limbs  become  cold  and 
damp,  and  capillary  cyanosis  develops  at  the  last.  The 
duration  from  perforation  to  the  death  of  the  patient  in 
this  condition  may  vary  from  two  to  five  <la>^.  From 
the  first   there  is  intestinal  stasis,  as  a  rule,  absolute; 


222  Duodenal  Ulcer 

neither  flatus  nor  faeces  are  passed  except  in  response  to 
repeated  enemata,  and  then  only  in  meagre  quantity. 

Such  is  the  course  followed  in  the  majority  of  cases, 
unless  surgical  treatment  is  adopted.  It  is  modified 
only  by  the  administration  of  morphine,  which  may 
work  wonders  in  the  apparent  improvement  of  the 
patient's  condition.  It  brings  back  a  look  of  comfort 
to  the  face,  warmth  to  the  limbs,  and  ease  from  suffering; 
but  its  effect  is  brief,  and  large  and  repeated  doses  have 
to  be  given  to  produce  a  response.  As  soon  as  the  effect 
begins  to  wear  away  the  pain  returns.  The  constant 
repetition  of  the  drug  will  do  much  to  blind  the  medical 
man  to  the  true  condition  of  the  patient;  the  symptoms 
are  masked.  It  is  owing  to  the  effect  of  the  constantly 
repeated  doses  of  morphine,  in  these  and  in  similar 
cases,  which  improve  the  patient's  condition  while  they 
blind  the  surgeon,  that  the  use  of  the  drug  has  been 
entirely  suspended  in  the  practice  of  many.  Many  of  us 
have  become  frightened  of  the  drug,  quite  needlessly, 
for  properly  used  its  value  is  beyond  question. 

It  is  remarkable  how  constantly  the  right  side  of  the 
abdomen  is  chiefly  affected.  The  tenderness  and  the 
rigidity,  though  everywhere  present,  are  often  more  pro- 
nounced on  the  right  side,  at  the  upper  or  lower  parts, 
or  throughout  the  whole  extent.  So  often  is  this  the 
case  that  a  diagnosis  of  appendicitis  has  frequently  been 
made,  and,  indeed,  has  been  acted  upon,  the  appendix 
being  removed  without  any  suspicion  being  aroused  as 
to  the  true  place  of  origin  of  the  peritoneal  invasion. 
I  called  attention  to  this  fact  and  to  its  explanation  in 
my  first  paper  on  "Duodenal  Ulcer"  ("Lancet,"  1901, 


Perforation  223 

ii,  1656).  In  that  article  49  cases  of  perforating  duo- 
denal ulcer  treated  by  operation  were  reviewed ;  in  no 
fewer  than  19  had  a  diagnosis  of  appendicitis  been  made. 
The  reason  for  this  mimicry  of  appendicitis  is  that  fluid 
escaping  from  the  rent  in  the  duodenum  trickles  down- 
wards to  the  upper  surface  of  the  transverse  mesocolon 
to  the  right  of  the  hillock  which  is  formed  by  the  fitting 
in  of  the  transverse  colon  to  the  greater  curvature  of 
the  stomach.  It  is  then  directed  downwards  to  the 
hepatic  flexure,  and  to  the  outer  side  of  the  ascending 
colon,  to  till  the  "kidney  pouch"  described  by  Ruther- 
ford M orison.  Thence  it  flows,  still  in  a  downward 
direction,  to  the  iliac  fossa  and  the  pelvis.  The  tendency 
of  the  fluid  to  drift  in  this  particular  direction  has  been 
studied  experimentally  by  Maynard-Smith  ("Lancet,"' 
1906,  i,  895),  who  writes: 

"With  a  view  to  investigate  the  course  taken  by  fluid 
from  a  perforated  duodenal  ulcer  I  have  carried  out  a  series 
of  experiments  on  the  dead  body.  The  pathological  condition 
was  reproduced  by  passing  an  oesophageal  tube  into  the 
stomach  from  the  mouth  and  attaching  to  it  a  gla--  tube 
which  was  passed  through  the  pylorus  and  broughl  out  of  a 
hole  in  the  duodenum  in  the-  usual  site  of  perforation.  The 
end  of  t bi^  tube  was  then  tied  in  flush  with  the  duodenal 
surface,  h  was  possible  to  do  this  without  disturbing  the 
anatomical  condition  of  the  parts.  The  incision  in  the  ab- 
dominal wall  made  for  the  purpose  of  these  manipulations 
was  then  closed.  By  means  of  a  funnel  attached  to  the 
oesophageal  tube  thud  was  nm  down  it  and  made  its  exit  into 
the  peritoneal  cavity  at  the  site  of  a  perforated  duodenal 
ulcer.  The  fluid  used  was  water  with  zinc  oxide  suspended 
in  it  by  means  ol  tragacanth  emulsion.  In  every  instance  the 
fluid  ran  downwards  in  the  direction  oi  the  right  kidney  pouch 
and  collected  in  a  space  bounded  by    -in  front,  the  under  sur- 


224  Duodenal  Ulcer 

face  of  the  right  lobe  of  the  liver  and  the  hepatic  flexure  of 
the  colon;  behind,  the  anterior  peritoneal  covered  surface  of 
the  right  kidney  and  the  posterior  abdominal  wall;  outside,  the 
curve  of  the  abdominal  wall;  and  inside,  the  duodenum  itself 
and  the  foramen  of  Winslow.  In  an  upper  direction  this 
pouch  spreads  behind  the  liver,  between  the  viscus  and  the 
diaphragm,  but  here  its  process  is  blocked  by  the  inferior 
layer  of  the  coronary  ligament.  Away  from  the  middle  line, 
however,  it  stretches  uninterruptedly  to  the  right  of  the  lateral 
hepatic  ligament  to  the  upper  surface  of  the  liver  as  far  as 
the  reflection  of  the  falciform  ligament.  Downward  this 
space  is  limited  in  part  by  the  reflection  of  peritoneum  from 
the  hepatic  flexure  of  the  colon  on  to  the  surface  of  the  kidney 
and  the  second  part  of  the  duodenum.  When  fluid  had  filled 
up  the  right  kidney  pouch,  it  always  followed  certain  definite 
paths.  It  did  not  pass  through  the  foramen  of  Winslow  into 
the  lesser  sac  of  peritoneum.  It  had  little  tendency  to  find 
its  way  beneath  the  diaphragm.  It  always  descended  along 
the  outer  side  of  the  ascending  colon  as  far  as  the  brim  of 
the  pelvis.  The  level  of  the  fluid  rose  until  it  reached  the 
level  of  the  pelvic  brim.  It  then  overflowed  into  the  pelvis. 
It  must  be  remembered  that  this  collecting  body  of  fluid 
is  dammed  up  on  the  inner  side  by  the  ascending  colon.  If 
this  has  no  mesentery,  the  colon  may  be  so  bound  down  into 
the  loin  that  the  level  of  the  fluid  reaches  above  the  summit 
of  the  ascending  colon  'dam'  before  it  rises  above  the  level 
of  the  brim  of  the  pelvis.  In  this  case  the  fluid  will  first 
leave  the  right  kidney  pouch  by  crossing  the  ascending  colon 
—usually  a  few  inches  below  the  hepatic  flexure.  Even 
if  the  fluid  takes  this  course,  it  still  tends  to  flow  to  the  appen- 
dix region,  guided  thither  by  the  obliquity  of  the  mesentery 
downwards  and  to  the  right  and  by  the  slope  of  the  abdominal 
wall  away  from  the  middle  line.  It  does  not  directly  invade 
the  left  half  of  the  abdomen,  but  crosses  the  termination  of 
the  ileum  and  reaches  the  right  side  of  the  pelvis  practically 
at  the  same  spot  as  before." 

The  fluid  escaping  from  the  duodenum  is  from  the 
first  prevented  from  going  to  the  left  by  the  peritoneal 


Perforation  225 

reflection  of  the  great  omentum  from  the  duodenum  and 
the  stomach.  If  the  body  be  erect,  the  fluid  escapes 
by  the  low  opening  in  the  cavity,  and  trickles  down  the 
side  of  the  colon.  If  the  body  be  recumbent,  the  fluid 
gravitates  to  the  renal  pouch.  In  both  positions  the 
foramen  of  Winslow  lies  at  a  higher  level  and  does  not 
allow  of  the  entrance  of  fluid  into  the  lesser  sac. 

DIFFERENTIAL  DIAGNOSIS 
There  are  very  few  cases  in  which  a  doubt  as  to  the 
diagnosis  should  exist.  The  early  history  of  the  case  is 
of  the  greatest  possible  significance.  In  my  own  experi- 
ence a  perfectly  clear  account  of  the  characteristic  symp- 
toms of  duodenal  ulcer  can  usually  be  obtained.  It 
is  true  that  in  some  of  the  recorded  cases  it  is  said  that 
there  were  no  previous  symptoms  or  that  "only  a  little 
indigestion"  had  been  noticed.  Such  statements  require 
close  examination;  in  the  light  of  the  more  accurate 
knowledge  we  now  possess  as  to  the  characteristic  mani- 
festations of  duodenal  ulcer  they  cannot  be  accepted. 
We  know  that  in  all  the  cases,  other  than  the  acute 
toxic  cases,  it  is  a  chronic  ulcer  of  the  duodenum  which 
perforates;  and  no  chronic  ulcer  of  the  duodenum  exists 
without  betraying  its  presence  by  symptoms  which  to 
those  cognisanl  of  them  are  of  the  clearest  significance. 
Of  all  the  aids  to  accuracy  in  diagnosis,  there  is  none 
that  can  compare  with  that  given  by  the  anamnesis. 
The  character  of  the  pain  affords  substantial  help  also, 
for  it  is  of  so  intense  a  se\  erity  as  to  put  .ill  Inn  .1  lew  ot 
the  abdominal  catastrophes  out  of  consideration.  The 
pain  is  overwhelming;    it  i-  referred,  .1-  a  rule,  to  the 


226  Duodenal  Ulcer 

whole  abdomen;  only  rarely  is  it  localised  to  the  right 
side,  or  is  any  mention  made  of  pain  in  the  back,  or  of 
pain  radiating  to  the  clavicle  (Crawford  Renton)  or 
breasts.  Within  two  or  three  hours,  however,  the  pain 
is  almost  always  of  greater  severity  on  the  right  side,  and 
certainly  the  sensitiveness  and  the  rigidity  are  excessive 
there.  The  rigidity  from  the  first  is  absolute.  No 
other  condition  than  a  perforation  of  the  stomach  or 
the  duodenum  ever  gives  rise  to  such  unalterable  and 
unyielding  tension  in  the  muscles.  Rigidity  is  a  sign 
common  to  many  acute  intra-abdominal  diseases;  it 
is,  of  course,  nothing  more  than  a  protective  barrier 
to  ward  off  attack  or  a  muscular  splint  to  ensure  rest. 
But  in  no  other  disease,  as  far  as  my  observation  goes, 
is  the  rigidity  so  complete  and  absolute,  in  none  does 
it  persist  so  unchanged,  as  in  cases  of  gastric  or  duodenal 
perforation.  Rigidity  to  this  extent  implies  retraction, 
which  does  not  vanish  till  the  distension  due  to  peri- 
tonitis begins  to  develop;  the  rigidity,  however,  does 
not  lessen  until  toxaemia  is  profound,  and  capillary 
cyanosis  with  clammy  extremities  are  the  plainest 
warning  that  death  is  imminent. 

The  differentiation  of  a  duodenal  from  a  gastric  per- 
foration is  not  usually  a  matter  of  any  difficulty.  The 
early  history,  of  course,  differs.  The  character,  time  of 
onset,  site,  radiation,  and  relief  of  the  pain  are  all  differ- 
ent in  the  two  cases.  After  perforation  it  is  possible,  by 
careful  examination  of  the  abdomen,  to  discover  an  area, 
both  more  resistant  and  more  tender  than  any  other; 
it  is  almost  as  though  a  local  phlegmon  were  present. 
Beneath  that  area  lies  the  ulcer,  in  all  probability.     Alex- 


Perforation  227 

ander  Miles  has  also  noted  this  fact.  He  writes  ("  Edin. 
Med.  Journ.,"  1906,  ii,  224):  "I  have  found  a  remark- 
able correspondence  between  the  site  of  the  maximum 
tenderness  and  the  seat  of  the  perforation.  When  the 
most  tender  area  was  in  the  left  hypochondrium,  the 
perforation  has  almost  invariably  been  towards  the 
cardiac  end  of  the  stomach ;  when  around  the  umbilicus, 
in  the  body  of  the  stomach;  and  when  in  the  right 
hypochondrium,  near  the  pyloric  end  or  in  the  duodenum. 
So  constant  is  this  association  that  I  have  come  to  rely 
upon  it  as  a  guide  to  the  site  of  incision." 

As  I  have  already  said,  the  chief  pitfall  lies  in  the  close 
mimicry  of  the  symptoms  of  appendicitis.  In  both,  the 
attacks  begin  abruptly,  the  pain  is  sudden  in  onset, 
acute,  referred  often  to  the  epigastrium  or  to  the  whole 
abdomen,  and  later  it  is  upon  the  right  side  of  the  abdo- 
men that  the  chief  stress  of  the  disease  falls.  But  the 
history  again  is  the  chief  factor  upon  which  to  place 
reliance.  The  perforation  in  an  appendix  case  is  not 
preceded  by  any  "indigestion,"  at  least  not  of  the  char- 
acteristic duodenal  type.  In  appendicitis  of  the  acute 
perforative  variety  a  history  of  some  slight  pain  or  con- 
stipation is  usually  to  be  heard,  and  an  aperient  has 
always  been  taken.  Acute  perforative  appendicitis  in 
almost  every  case  I  see  is  caused,  immediately,  by  an 
aperient.  Moreover,  the  rigidity  in  appendicitis  is  not 
to  be  compared  in  intensity  with  that  in  duodenal  per- 
foration, nor  is  the  agony  so  intolerable;  the  diaphragm 
is  not  so  tightly  held,  and  therefore  the  breathing  is  not 
of  the  same  short,  jerky  character.  In  both  there  is 
tenderness  in  the  iliac  fossa,  and  in  both  there  may  be 


228  Duodenal  Ulcer 

tenderness  extending  up  to  the  liver  if  the  appendix 
chances  to  lie  along  the  ascending  colon.  But  the  rela- 
tive tenderness  and  rigidity  are  different.  In  cases  of 
duodenal  ulcer  they  are  never  lacking  in  the  right  hypo- 
chondrium ;  in  cases  of  appendicitis  they  are  only 
exceptionally  there,  and  then  are  of  no  great  severity. 
It  is  true,  as  I  pointed  out,  that  the  mistake  most  fre- 
quently committed  before  1901  was  that  of  considering 
a  large  proportion  of  cases  of  duodenal  perforation  as 
cases  of  appendicitis.  But  since  attention  was  then 
drawn  to  the  matter,  the  mistakes  have  been  few.  Be- 
fore then  the  operations  for  perforating  ulcer  were 
infrequent;  now  they  are  within  the  province  of  very 
many  surgeons,  and  ease  of  diagnosis  has  come  with 
increase  of  experience. 

There  are  a  few  cases,  it  is  well  to  remember,  in  which 
the  two  conditions,  appendicitis  and  perforated  duodenal 
ulcer,  have  coexisted.  Case  6  in  my  own  series  of  per- 
foration is  a  good  example,  and  others  are  recorded  by 
Bolton  Carter  ("Lancet,"  1901,  ii,  1195)  and  Lediard 
and  Sedgwick  ("Lancet,"  1904,  ii,  761),  and  there  are  a 
large  number  in  which  a  gastric  perforation  and  appen- 
dicitis have  occurred  almost  simultaneously. 

Acute  pancreatitis  may  present  difficulties  of  dis- 
crimination from  perforated  ulcer  of  the  duodenum. 
As  a  rule,  there  have  been  no  inaugural  symptoms  in 
cases  of  acute  pancreatic  inflammation,  though  the 
occasional  dependence  of  this  condition  on  the  impac- 
tion of  a  stone  in  the  ampulla  of  Vater  is  evidence  that 
the  characteristic  "dyspeptic  symptoms"  of  gall-stones 
may  have  been  present  for  months  or  years  before.     The 


Perforation  229 

pain  in  acute  pancreatitis  is  always  worse  in  the  epigas- 
trium, and  it  is  there  that  the  resistance,  tenderness, 
and  subsequent  distension  are  found.  Acute  pancreatitis, 
indeed,  is  often  clinically  recognised  as  epigastric  peri- 
tonitis, and  the  enlarged  and  (^edematous  gland  may 
even  be  felt  on  deep  palpation.  In  the  cases  of  acute 
involvement  of  the  pancreas  the  pulse  is  bad  from  the 
first;  it  is  always  rapid,  thin,  of  poor  quality;  its  rate, 
indeed,  is  at  first  quite  disproportionate  to  the  severity 
of  all  the  other  symptoms  or  signs.  Vomiting,  too,  is 
more  conspicuous,  and  there  is  frequently,  as  Halsted 
was  the  first  to  note,  a  deep  lividity  or  cyanosis  of  the 
skin,  chiefly  of  the  face.  Pancreatitis  often  attacks 
corpulent  people,  and  it  is  not  seldom  met  with  in 
women  during  the  early  months  of  pregnancy.  A 
general  distension  of  the  abdomen  is  rare  in  acute 
pancreatitis;  the  right  side  of  the  abdomen  is  not 
specially  involved;  and  the  hurried,  jerky  respiration, 
due  to  the  fixed  contraction  of  the  diaphragm,  is  not 
seen.  The  differential  diagnosis  should  be  made  with 
confidence;  though  I  must  confess  to  the  commission 
of  the  error  in  the  second  case  of  acute  pancreatitis 
that  I  saw.  The  patient,  a  fat  man,  inclined  to  the  free 
use  of  alcohol,  had  a  lividity  of  the  face,  and  in  less  degree 
of  the  body,  which  should  have  given  me  the  chic  to  a 
correct  diagnosis.  The  discovery  of  tat  necrosis  in  the 
subperitoneal  fat  made  the  diagnosis  certain  before  the 
peritoneum  was  incised.  'See  "Brit.  Med.  Journ.," 
[911,  i,  733.) 

<  >ne  ot    the   most    perplexing  difficulties   which   ma) 
confront   the  surgeon  lies  in  the  proper  discrimination 


230  Duodenal  Ulcer 

of  acute  catastrophes  arising  in  .the  gall-bladder  from 
those  which  have  their  origin  in  the  duodenum.  An 
acute  perforation  of  the  gall-bladder  may  present  iden- 
tical symptoms,  both  local  and  general;  and  nothing 
but  a  careful  analysis  of  the  previous  history  can  ensure 
an  accurate  diagnosis.  I  have  only  operated  upon  one 
case  of  a  ruptured  gall-bladder  in  which  the  differential 
diagnosis  needed  close  consideration  and  discussion. 
The  anamnesis  revealed,  however,  a  definite  history  of 
hepatic  colic,  with  jaundice  on  more  than  one  occasion; 
the  local  tenderness  was  wholly  disproportionate  to  the 
general  sensitiveness  of  the  body,  and  the  illness  of  the 
patient,  which  had  extended  over  nearly  forty-eight 
hours,  though  it  was  serious,  did  not  seem  so  desperate 
as  would  have  been  the  case  had  the  duodenum  given 
way. 

Perhaps  the  most  disconcerting  of  the  diagnostic 
disasters  which  have  occurred  are  those  in  which  an 
acute  thoracic  disease  has  been  mistaken  for  an  acute 
catastrophe  in  the  abdomen,  and  an  operation  per- 
formed. I  have  myself  been  twice  summoned  to  oper- 
ate for  "perforated  ulcer  of  the  stomach  or  duodenum," 
and  after  examination  have  made  what  proved  to  be 
a  correct  diagnosis  of  pleurisy  and  pneumonia.  The 
mimicry  is  more  commonly  of  appendicitis,  however, 
than  of  perforation  of  a  duodenal  ulcer. 

It  is  extraordinary  with  what  accuracy  an  acute 
intrathoracic  disease  may  clothe  itself  with  the  symp- 
toms and  the  signs  of  an  abdominal  disorder.  In  cases 
of  pleurisy,  especially  diaphragmatic  pleurisy,  of  pneu- 
monia, or  of  acute  bronchitis,  the  onset  may  be  sudden, 


Perforation  231 

the  pain  may  be  felt  exclusively  in  the  abdomen,  the 
abdominal  muscles  may  be  tense,  and  the  surface  of 
the  body  extremely  tender.  Indeed,  unless  the  close 
simulation  of  acute  abdominal  lesions  by  disease  above 
the  diaphragm  be  remembered,  the  most  expert  of 
surgeons  may  be  deceived.  Both  Dr.  Maurice  Rich- 
ardson ("Boston  Med.  and  Surg.  Journal,"  1902,  i, 
399)  and  Mr.  Harold  Barnard  ("Lancet,"  1902,  ii, 
280),  who  almost  simultaneously  drew  attention  to  this 
subject,  record  cases  in  which  operation  was  unwisely 
done,  and  the  former,  in  an  article  of  characteristic 
literary  felicity  and  charm,  gives  a  detailed  account  of 
one  case  in  which  he  advised  against  operation  in  the 
belief  that  the  patient  was  not  suffering  from  any 
abdominal  disease  requiring  it;  a  colleague  operated 
at  once,  and  found  a  perforated  appendix  and  free  pus 
in  the  peritoneal  cavity.  The  following  case,  related  by 
Mr.  Barnard,  is  perhaps  the  most  perplexing  of  all: 

"A  girl,  aged  seventeen,  had  been  attending  the  out-patient 
department  of  the  London  Hospital  for  some  months  for 
marked  anaemia  and  gastric  ulcer.  She  had  had  once  before 
a  similar  attack  to  the  one  which  I  am  about  to  describe.  One 
morning  in  [899  -Ik-  started  lor  work  as  usual,  and  on  her  way 
was  seized  in  the  street  with  violent  epigastric  pain  and  vomit- 
ing. She  was  brought  to  the  hospital  at  once  in  a  state  of 
collapse.  Her  pulse  was  120  and  very  thready,  and  her  tem- 
perature was  104. 50  F.  Her  abdomen  was  rigid,  motionless, 
very  tender,  and  distended,  and  these  signs  were  must  marked 
in  the  epigastric  region.     She  was  admitted   to  the  surgical 

ward  .1-    1  case  of  ruptured  gastric  ulcer,  and  within  two  hours 

Mr.  Eve  opened  her  abdomen.  He  explored  the  anterior  and 
posterior  surfaces  of  the  si  on  1,1  eh,  the  greater  and  lesser  curva- 
tures, but  found  no  trace  of  gastric  ulcer,  nor  was  there  an} 
peritonitis.     Unfortunately,  ether  was  the  anaesthetic  given. 


232  Duodenal  Ulcer 

Misfortunes  followed  fast.  Her  cough  became  so  violent  that 
a  coil  of  intestine  and  some  omentum  escaped  between  the 
stitches  and  had  to  be  washed  and  returned  and  the  abdomen 
again  sewn  up.  On  the  second  day  after  admission  it  was 
clear  that  she  had  basal  pneumonia,  but  her  temperature  had 
fallen  to  1010.  On  the  third  day  it  rose  again  to  1040  and  signs 
of  consolidation  appeared  at  the  left  base,  and  she  died  on  the 
fifth  day  from  the  commencement  of  the  attack.  At  the  post- 
mortem examination  double  basal  pneumonia  and  right  dia- 
phragmatic pleurisy  were  found,  and  in  the  stomach  was  a 
shallow  ulcer  of  the  size  of  a  sixpenny  piece  which  was  not 
even  near  to  perforation.     There  was  no  peritonitis." 

The  fact  that  a  lesion  lying  above  the  diaphragm  may 
be  the  whole  explanation  of  symptoms  and  signs  observed 
below  it  is  one  that  the  surgeon  can  never  afford  to 
forget. 

The  points  of  chief  significance  upon  which  stress 
should  be  laid  in  order  to  prevent  a  mistake  of  this  sort 
being  committed  are:  (a)  The  temperature.  This  is 
the  most  important  of  all.  It  is  rare  in  any  case  of 
acute  abdominal  lesion  to  find  the  temperature  raised 
to  1020  or  more.  In  the  acute  thoracic  conditions  the 
temperature  may  range  between  1030  and  1050.  (b) 
Rapidity  of  respiration;  in  several  of  the  recorded  cases 
the  rate  has  been  40  to  the  minute  or  more,  (c)  Dis- 
proportion between  the  rate  of  the  pulse  and  the  rate 
of  respiration.  The  pulse  is  not  much  over  100  in  the 
acute  lesions  within  the  chest,  while  the  respiration 
may  be  between  35  and  45.  A  pulse-rate  of  120  and  a 
respiratory  rate  of  25  would  be  more  commonly  recorded 
in  an  abdominal  case,  (d)  The  condition  of  the  abdo- 
men in  respect  of  rigidity  and  tenderness.  There  is 
never  the  same  unchanging  resistance  of  the  abdominal 


Perforation  233 

wall  in  any  chest  condition  as  there  is  when  the  lesion 
is  in  the  belly,  nor  is  the  tenderness  more  than  super- 
ficial. The  area  affected  is  limited,  and  the  amount  of 
its  involvement  is  less.  When  the  hand  first  touches 
the  abdomen,  pain  may  be  felt,  but  deeper  pressure  may 
even  give  relief,  and  during  the  respiratory  act  a  moment 
at  the  height  of  the  expiratory  phase  may  find  the 
muscles  soft  and  yielding  to  the  hand,  (e)  Comparative 
tranquillity  at  the  lower  part  of  the  chest,  the  respiratory 
movements  in  the  upper  costal  zone  being  exaggerated 
in  cases  where  the  diaphragmatic  pleura  is  inflamed. 

The  position  is  very  clearly  stated  by  Dr.  Maurice 
Richardson  in  these  words: 

"The  diagnosis  between  acute  thoracic  and  acute  abdominal 
disease  is  always  easy  as  soon  as  the  characteristic  signs  of 
either  are  apparent.  The  chief  difficult}'  in  making  a  dis- 
tinction is  to  recognise  that  the  necessity  for  that  distinction 
exists,  for  the  thoracic  symptoms  are  always  masked  by  the 
more  conspicuous  and  distressing  abdominal  ones.  Once 
the  attention  is  drawn  to  the  possibility  of  a  thoracic  cause, 
not  only  for  the  thoracic,  but  for  the  abdominal  symptoms, 
an  accurate  diagnosis  is  perfectly  easy." 

TREATMENT 
In  all  cases  where  an  acute  abdominal  catastrophe 
has  occurred  the  surgeon  is  called  upon  to  display  the 
best  qualities  he  possesses  if  a  good  result  to  the  patient 
is  to  be  ensured.  Quickness  in  operating,  a  sound 
judgment,  and  the  light  hand  are  all  essential.  When 
a  duodenal  ulcer  has  perforated,  these  things  combined 
will  do  much  to  save  the  patient's  life;  absence  of  any 
one  of  them  may  lead  to  disaster. 


234  Duodenal  Ulcer 

As  soon  as  a  decision  to  operate  has  been  made,  I  give 
the  patient  a  hypodermic  injection  of  morphine,  gr.  >£, 
with  or  without  scopolamine,  gr.  yvt>>  unless  this  has 
been  recently  administered  by  the  medical  attendant. 
It  cases  the  intolerable  agony  of  the  patient,  makes  the 
ordeal  of  preparation  for  operation  less  terrifying,  and 
it  permits  of  the  giving  of  a  less  quantity  of  ether  (the 
only  anaesthetic  I  allow  for  these  cases)  than  would 
otherwise  be  necessary.  The  patient  will  often  have  a 
quiet  and  most  refreshing  sleep  of  two  or  three  hours 
after  operation  if  scopolamine  be  given,  and  the  nausea 
caused  by  the  anaesthetic  is  sensibly  diminished.  Every 
instrument  is  boiled,  every  needle  threaded,  every  liga- 
ture ready  to  hand,  before  the  anaesthetic  is  administered. 
While  the  patient  is  going  to  sleep  the  final  preparation 
of  the  skin  of  the  whole  of  the  abdomen  is  made.  It 
is  in  these  cases,  when  the  free  rubbing  of  the  abdomen 
has  been  impossible,  that  the  application  of  Harrington's 
solution  as  the  final  part  of  the  cleansing  proves  so  use- 
ful; it  ensures  the  sterility  of  the  skin  better  than  any- 
thing else.  As  soon  as  the  patient  is  ready,  and  not  one 
moment  later,  the  operation  begins.  The  diagnosis  will 
have  been  made  with  such  confidence  that  the  incision 
through  the  right  rectus,  as  for  the  operation  of  gastro- 
enterostomy, will  be  made.  At  the  moment  the  peri- 
toneum is  incised  there  is  a  rush  of  gas  and  a  few  bub- 
bles escape.  The  gas  and  the  fluid  which  rapidly 
follows  are  both  inodorous  and  the  fluid  is  usually 
sterile.  The  incision  in  the  peritoneum  is  rapidly 
enlarged  and  the  exposure  of  the  ulcer  is  made.  As  a 
rule,  there  is  much  thick  lymph  around  and  about  the 


Perforation  235 

ulcer,  fixing  it  perhaps  to  the  under  surface  of  the  liver 
or  to  the  anterior  abdominal  wall.  The  omentum, 
the  "abdominal  policeman"  of  Rutherford  Morison,  is 
attached  by  recent,  thick,  moderately  firm  adhesions  to, 
or  near  to,  the  ulcer;  it  always  plays  its  part  in  endeav- 
ouring to  prevent  the  perforation  or  to  limit  the  extrava- 
sation when  the  rupture  has  actually  occurred.  When 
the  duodenum  is  thoroughly  exposed  by  the  wiping 
away  of  the  lymph  and  the  mopping  up  of  much  fluid, 
the  perforation  is  exposed.  Happily,  it  is  in  a  very 
great  majority  of  instances  on  the  anterior  surface  of  the 
duodenum,  and  immediately  beyond  the  pylorus.  Wher- 
ever it  lies  it  is  brought  as  far  as  possible  into  the  wound, 
and  a  few  flat  gauze  swabs  are  packed  into  the  abdomen 
around  it.  They  shut  off  the  operation  area  for  a  time, 
and  they  absorb  a  large  quantity  of  the  fluid  which  has 
already  escaped  into  the  abdomen.  The  ulcer  is  then 
dealt  with;  it  may  be  excised,  or  the  aperture  in  its 
base  may  be  closed  up  by  suture.  I  do  not  myself 
excise  the  ulcer,  because  it  needs  a  little  more  expenditure 
of  valuable  time  and  because  closure  of  the  ulcer,  as  A.  B. 
Mitchell,  of  Belfast,  has  shewn,  has  the  precise  effect 
which  the  removal  of  the  ulcer  produces.  I  close  the 
perforation  therefore  by  suture,  using  generally  a  single 
catgut  stitch  to  bridge  the  opening  and  to  prevent  leak- 
age during  the  subsequent  application  of  the  thread 
-t itches.  These  are  introduced  in  two  layers,  generally 
continuous,  but  sometimes  interrupted.  The  continu- 
ous suture  is  perfectly  satisfactory,  and  is  applied  with 
greater  rapidity  and  ease.  If,  however,  the  ulcer  is 
very  large,  I  usually  put  in  a  first  layer  <>f  interrupted 


236  Duodenal  Ulcer 

sutures,  if  it  appears  likely  that  these  will  have  to  be 
discharged  into  the  intestine.  It  is  best  always  to 
place  the  stitches  in  such  manner  that  the  resulting 
line  of  suture  is  vertical;  for  by  so  doing  there  is  less 
likelihood  of  any  stenosis  of  the  duodenum  being  caused, 
and  therefore  less  urgent  need  of  gastroenterostomy. 
After  the  suture  is  complete,  a  very  thorough  cleaning 
of  the  parts  around  is  necessary,  and  while  this  is  being 
done  the  stomach,  which  will  usually  be  found  distended, 
may  well  be  emptied  and  washed  out  by  the  anaesthetist. 
This  step,  which  I  first  suggested  some  years  ago,  is 
less  often  practised  than  it  should  be,  for  although  the 
pylorus  probably  remains  closed  for  a  few  hours  after 
operation,  the  stomach  contents,  often  abundant,  must 
either  be  vomited  or  passed  out  of  the  stomach  through 
the  duodenum  over  the  newly  sutured  line,  or  through 
a  new  anastomosis  made  into  the  jejunum.  Not  one 
of  the  alternatives  is  desirable  or  satisfactory;  the 
better  plan  is  to  empty  and  to  cleanse  the  stomach  so 
that  rest  for  a  few  hours  may  be  secured. 

The  toilet  of  the  peritoneum  is  better  done  thoroughly; 
between  the  liver  and  the  duodenum  and  in  the  renal 
pouch  of  Rutherford  Morison  there  will  probably  be  a 
large  accumulation  of  fluid  and  of  massive  layers  of 
lymph.  The  latter  should  be  taken  away;  the  former, 
in  so  far  as  it  consists  of  extravasated  materials  (cur- 
rants, pieces  of  vegetables,  and  other  gross  fragments 
of  food),  must  be  removed;  but  in  so  far  as  it  consists 
of  the  thin  serous  fluid  poured  out  freely  by  the  perito- 
neum in  response  to  the  alarm  of  invasion  of  its  cavity, 
may  be  left.     This  latter  fluid  is  certainly  sterile,  and 


Perforation  237 

probably  possesses  potent  qualities  for  resisting  intrusion 
by  any  infective  agent.  The  readiest,  and  in  most 
cases  the  only  necessary,  method  of  cleansing  consists 
in  the  wiping  of  all  soiled  areas  with  large,  soft  swabs 
sodden  with  hot  normal  saline  solution.  The  light 
hand  is  at  all  times  necessary;  the  heavy  scrubbing 
of  tender  peritoneal  surfaces  is  to  be  avoided.  The 
question  as  to  the  use  of  lavage  is  one  that  can  only  be 
decided  by  the  conditions  disclosed  at  the  operation. 
If  the  perforation  has  recently  occurred,  and  if  no 
foreign  materials  are  found  free  in  the  abdomen,  lavage 
is  not  necessary;  and  where  not  necessary,  is  possibly 
harmful.  But.  if  the  soiling  is  very  extensive  and  of 
such  a  character  that  the  peritoneum  cannot  deal  with 
it;  if,  that  is  to  say,  there  are  seeds,  currants,  lettuce, 
peas,  nuts,  bits  of  orange  (all  of  which  I  have  seen), 
then  free  lavage  is  certainly  needful.  I  am  fully  aware 
of  the  enormous  capacity  of  the  peritoneum  for  dealing 
with  material  left  behind  after  various  operations;  but 
I  am  equally  cognisant  of  the  limits  of  its  powers,  and 
of  the  fact  that  it  is  most  undesirable  to  test  those 
powers  to  the  furthest  limit.  Lavage,  then,  in  m\ 
experience,  though  generally  unnecessary,  is  sometimes 
imperative.  It  is  best  carried  out  by  means  of  a  glass 
funnel  with  three  or  four  feet  of  thick  rubber  tubing 
attached  to  it.  I  prefer  to  use  no  glass  tube  or  nozzle 
at  the  end;  the  rubber  tube  alone  is  equally  efficacious 
and  is  nol  SO  likely  to  do  harm.  Saline  solution  al  .1 
temperature  of  ioo°  to  [05  is  used,  and  it  is  important 
to  see  that  there  are  no  wide  variations  in  the  tempera- 
ture of  the  fluid  introduced.     The  most  common  fault 


238  Duodenal  Ulcer 

is  to  have  the  fluid  too  cold.  Before  the  flushing  begins 
a  tube  is  placed  into  the  pouch  of  Douglas  through  a 
small  suprapubic  incision.  The  peritoneal  cavity  is 
then  thoroughly  irrigated,  one  region  after  another,  in 
due  order.  It  is  best  to  cleanse  the  area  around  the 
perforation  first,  then  the  parts  beneath  the  diaphragm, 
and  then  to  descend  along  the  outer  side  of  the  ascend- 
ing colon  to  the  iliac  fossa  and  to  the  pelvis,  and  sub- 
sequently to  deal  similarly  with  the  left  side.  If  a 
special  tube  is  used  for  irrigation  purposes,  that  invented 
by  Dr.  Joseph  Blake,  of  New  York,  is  certainly  the  best; 
one  acting  upon  the  same  principle  is  used  by  Mr. 
Burgess,  of  Manchester.  Drainage  should  be  adopted, 
I  think,  as  a  rule.  In  cases  of  gastric  perforation  I 
have  seen  the  abdomen  almost  full  of  fluid  in  less  than 
two  hours,  and  the  pelvis  may  be  brimming  over  with 
a  thin  clear  or  slightly  turbid  fluid  when  all  other  parts 
of  the  abdomen  are  empty.  A  drainage-tube  passed 
through  the  lower  part  of  the  linea  alba  will  often  give 
vent  to  a  gush  of  fluid  as  soon  as  it  reaches  the  bottom 
of  the  pelvis.  I  use  a  rubber  tube  of  large  size,  split 
along  one  side  from  end  to  end.  Such  a  tube  drains 
the  general  peritoneum,  as  Yates  ("Surgery,  Gynaecology 
and  Obstetrics,"  1905,  i,  473)  has  shewn,  only  for  a  very 
few  hours;  but  it  is  precisely  in  those  few  hours  that  it 
is  necessary.  Doubtless  much  of  the  fluid  that  is  found 
in  the  abdomen  in  these  cases  is  poured  out  by  the 
peritoneum  in  a  hurried  response  to  the  irritation  of 
contents  escaping  from  the  gut,  but  it  is  safer  not  to 
presume  that  this  is  the  case;  but  even  so  its  office  has 
been  fulfilled  and  it  may  well  be  allowed  to  flow  away. 


Perforation  239 

The  original  abdominal  incision  may  be  completely 
closed  by  tier  sutures  in  the  usual  manner;  it  is  very 
rarely  necessary  to  insert  a  drain  here.  It  is  most  neces- 
sary always  to  bear  in  mind  the  presence  of  a  second 
ulcer,  which  may  or  may  not  have  perforated.  In  one 
of  my  cases  of  gastric  perforation  death  occurred  on  the 
eleventh  day,  from  the  perforation  of  a  second  ulcer 
which  had  not  been  observed  at  the  time  of  operation. 
The  perforation  of  a  duodenal  ulcer  five  days  after  the 
closure  of  a  ruptured  ulcer  of  the  stomach  is  recorded  by 
Clarke  and  Franklin  ("Lancet,"  1901,  ii,  1194). 

In  all  cases  of  duodenal  perforation  the  question  must 
arise  as  to  the  need  for  gastroenterostomy.  \\  nen  an 
ulcer  has  perforated,  the  closure  of  t\\e  resulting  aperture 
is  accomplished  by  folding  in  the  wall  of  the  intestine. 
In  a  tube  of  the  calibre  of  the  duodenum,  this  results  in 
narrowing.  Even  when  the  suture  is  made  with  the 
finest  accuracy,  and  the  stitches  inserted  along  a  vertical 
line,  some  amount  of  stenosis  is  almost  sure  to  follow 
at  once;  and  in  the  subsequent  contraction  of  healing 
this  will  very  probably  become  more  marked.  In  the 
first  case  of  perforated  duodenal  ulcer  upon  which  I 
operated  so  great  a  constriction  of  the  duodenum  was 
produced  by  the  sutures  that  I  found  it  necessary  to 
perform  gastroenterostomy  at  once.  I  have  since  then 
had  to  carry  out  a  similar  procedure  in  other  cases. 
It  was  this  experience  which  first  led  me  to  advocate 
the  performance  of  gastroenterostomy  in  all  eases  where 
a  narrowing  of  the  bowel  had  been  at  once  produced  by 
the  application  of  the  sutures,  or  where  it  was  likely 
to  be  caused  in  the  subsequent  contractions  which  would 


240  Duodenal  Ulcer 

occur  in  the  process  of  healing.  Other  writers  have 
since  advocated  the  routine  performance  of  gastro- 
enterostomy in  all  cases  of  perforation  of  the  stomach, 
but  my  experience  has  shewn  that  this  is  quite  unneces- 
sary. Gastro-enterostomy  is  only  to  be  done  in  those 
cases  where  an  obstruction  is  present  or  is  likely  to 
develop.  The  advantages  of  gastro-enterostomy  are: 
that  it  permits  a  more  assured  closing  of  the  ulcer,  for 
the  surgeon's  mind  is  not  filled  with  misgivings  as  to 
whether  his  suture  may  be  too  widely  taken;  that  it 
allows  of  the  early  unrestricted  administration  of  food; 
that  it  avoids  the  recurrence  of  the  ulcer,  or  the  develop- 
ment of  a  second  ulcer,  either  of  which  may  perforate. 
A.  B.  Mitchell  records  ("Trans.  Ulster  Med.  Soc," 
1908,  i,  68)  a  case  in  which  perforation  occurred  on 
July  21,  1907;  the  ulcer  was  closed  by  suture  and  the 
pelvis  drained;  a  second  perforation  occurred  on  March 
5.  1908,  and  a  second  operation — closure  of  the  ulcer 
and  gastro-enterostomy — was  performed  with  success. 
I  believe  it  to  be  the  best  practice,  therefore,  to  close  the 
ulcer  so  efficiently  as  to  cut  off  the  pyloric  outlet  from 
the  stomach,  and  to  perform  posterior  gastro-enteros- 
tomy Tor  anterior,  if  thought  better)  at  once.  In  my 
own  series  of  1 1  cases  gastro-enterostomy  was  done 
immediately  in  4,  and  became  necessary  at  a  later  date 
in  1.  One  of  the  patients  (Case  8)  would  certainly 
have  needed  a  short-circuiting  operation  had  he  survived. 
As  soon  as  the  patient  is  returned  to  bed,  he  is  propped 
up  in  the  sitting  posture,  and  continuous  rectal  infusion 
Murphy's  method)  is  at  once  begun.  This  I  consider  a 
most  essential  feature  of  the  treatment,  and  I  feel  that 


Perforation  241 

no  small  measure  of  the  success  attained  in  recent  cases 
is  attributable  to  this  procedure.  The  sitting  position 
is  more  comfortable  for  the  patient,  and  allows  drainage 
to  occur  to  the  pelvis,  which  is  tapped  by  the  rubber 
tube.  The  mouth  is  flushed  frequently,  the  teeth 
brushed,  and  the  tongue  kept  clean.  After  the  first 
six  or  eight  hours  fluid  may  be  given  by  the  mouth; 
there  is,  however,  rarely  any  thirst  if  the  fluid  is  prop- 
erly introduced  into  the  rectum.  The  rubber  drainage- 
tube  remains  in  for  about  thirty-six  hours,  more  or  less, 
according  to  the  amount  of  fluid  which  is  discharged 
through  it.  An  aperient  enema  is  given  every  twenty- 
four  hours;  a  hypodermic  injection  of  eserine  sulphate, 
gr.  Tly(7,  in  doses  repeated  at  intervals  of  two  hours  until 
three  or  four  doses  have  been  given,  if  flatulence  is 
troublesome;  and  a  dose  of  castor  oil  or  other  laxative 
is  given  on  the  evening  of  the  third  day. 

The  treatment  of  perforating  duodenal  ulcer  has  now- 
attained  a  remarkable  degree  of  safety.  The  best 
record  of  which  I  have  knowledge  is  that  of  Mitchell, 
of  Belfast,  who  has  operated  on  19  cases  with  18  recov- 
eries— a  record  of  which  this  accomplished  surgeon  may 
well  be  proud.  A  record  of  10  cases  is  contained  in  a 
paper  of  the  first  importance  by  Alexander  Miles 
("Edin.  Med.  Journ.,"  1906,  ii,  106). 

The  first  successful  case  of  operation  for  perforated 
ulcer  of  the  duodenum  is  recorded  by  Dean  ("Brit.  Med. 
Journ.,"  1894,  i,  1014);  the  patient  died  two  months 
later  from  ileus.  The  firsl  completely  successful  case 
was    treated    by    Dunn   ("Brit.    Med.    Journ.."    [896,    i. 

846  . 

16 


242  Duodenal  Ulcer 

SUBACUTE  PERFORATION 

The  foregoing  description  applies  to  cases  of  acute- 
perforation.  I  shewed  some  years  ago  that  in  a  f ew 
cases  the  perforation  was  less  violent  in  its  character 
and  in  its  results  than  this,  and  that,  accordingly,  a 
condition  of  "subacute"  perforation  should  be  recog- 
nised. I  have  discussed  this  condition  in  full  and 
reported  a  series  of  cases  illustrating  it  ("Annals  of 
Surgery,"  1907,  xlv,  223).  The  condition  of  "subacute 
perforation  of  an  ulcer  in  the  stomach  or  in  the  duodenum 
is  one  which  has  received  less  attention  than  it  merits. 
It  is  not  infrequent,  it  is  of  great  interest,  and  its  dis- 
crimination from  "acute"  perforation  is  of  no  little 
importance  from  the  therapeutic  standpoint. 

In  subacute  perforation  of  the  duodenum  there  is  a 
sudden  rupture  of  an  ulcer,  an  ulcer  which,  without 
exception  in  my  experience,  is  of  the  "chronic"  type. 
The  chronic  ulcer,  with  its  deep  excavation,  its  steep 
edge,  and  its  surrounding  induration,  has  eroded  the 
walls  of  the  stomach  little  by  little,  until  finally  and 
abruptly  the  thin  barrier  between  it  and  the  peritoneal 
cavity  is  broken  through.  The  conditions  are,  up  to 
this  point  and  in  these  particulars,  in  no  way  different 
from  those  existing  in  "acute"  perforation.  But  whereas 
in  the  latter  form  the  rupture  is  of  fair  size  and  at 
once  allows  the  contents  of  the  gut  to  spread  themselves 
freely  over  the  general  peritoneal  cavity,  and  to  cause 
there  a  universal  infection,  in  subacute  perforation 
there  is,  by  one  agency  or  another,  a  definite  localisation 
of  the  fluids  escaping  from  the  stomach,  and  in  many 


Perforation  243 

instances    a   narrow    circumscription    of    the    peritoneal 
response  to  their  invasion. 

It  becomes  a  matter  of  interest,  therefore,  to  know 
the  circumstances  under  which  this  limitation  is  affected. 
I  have  seen  examples  of  the  following: 

(1)  An  empty  condition  of  the  stomach.  In  "acute" 
perforation  the  stomach  is  often  full;  the  rupture  of  the 
ulcer,  it  is  frequently  remarked,  occurs  soon  after  a 
meal.  If  the  stomach  be  empty,  say  five  or  six  hours 
after  a  meal,  perforation  may  still  occur,  but  there  is, 
of  course,  little  or  no  escape  of  contents.  In  such  cir- 
cumstances the  ulcer  may  be  ruptured  by  a  violent 
strain,  a  sudden  movement,  or  a  severe  shake.  It  is 
not  long  before  a  most  vigourous  defence  is  made  by  the 
peritoneum,  lymph  is  thrown  out  copiously  in  flakes, 
and  a  thin  serous  fluid  begins  to  fill  the  peritoneal  cavity. 
The  escaping  contents  of  the  duodenum,  being  small  in 
quantity  and  feeble  in  bacterial  activity,  are  rapidly 
circumscribed. 

(2)  The  plugging  of  the  opening  in  the  ulcer  with  a 
tag  of  omentum.  Of  this  I  have  seen  one  perfect  ex- 
ample. The  ulcer  was  close  to  the  pylorus;  its  open- 
ing small;  into  this  opening  there  fitted,  as  accurately 
as  any  cork,  the  bulbous  end  of  a  thin  omental  tag 
which  came  upwards  from  the  greater  curvature  of  the 
stomach.  There.was  not  any  adhesion  of  the  stomach 
to  the  abdominal  wall  or  to  the  overhanging  liver;  nor 
was  there  need  for  any,  for  a  more  perfect  plugging  of 
an  opening  could  no1  be  conceived.  The  little  omental 
tag  seemed  quite  to  have  grown  into  the  opening  which 
it  so  securely  closed. 


244  Duodenal  Ulcer 

(3)  The  opening  may  be  sealed  over  by  layers  of 
plastic  lymph.  When  the  abdomen  is  opened,  a  clear 
and  slightly  turbid  fluid  is  found,  but  no  ulcer  is  appar- 
ent. At  some  part  of  the  stomach  wall  a  thick  adherent 
mass  of  plastic  lymph  will  be  seen  as  thick  as  wash- 
leather,  and  in  appearance  very  similar.  On  peeling 
this  off  a  small  perforation  is  found,  from  which  a 
bubble  may  be  squeezed.  This  condition  may  be  a 
later  stage  of  that  already  referred  to  (No.  1),  but  it  is 
equally  possible  that,  as  the  ulcer  deepens,  the  perito- 
neum is  irritated,  and  protectively  deposits  layer  after 
layer  of  lymph  upon  the  outer  side  of  the  base  of  the 
ulcer,  so  that  when  the  final  dissolution  of  the  wall  occurs, 
there  is  already  a  barrier,  almost  or  entirely  impenetra- 
ble, to  check  the  escape  of  the  stomach  contents. 

(4)  The  duodenum  becomes  adherent  at  the  base  of 
the  ulcer.  The  adhesion  may  be  to  the  anterior  abdom- 
inal wall,  to  the  under  surface  of  the  liver,  or  to  the 
pancreas. 

Symptoms. — In  every  particular  save  one,  that  is, 
intensity,  the  symptoms  are  the  same  in  subacute  as  in 
acute  perforation.  There  is  a  sudden  onset  of  pain, 
severe  and  almost  intolerable,  but  measurably  less  than 
in  acute  perforation.  The  pain  comes  almost  without 
exception  in  those  who  have  suffered  for  years  or  months 
from  the  usual  symptoms  of  duodenal  ulceration.  There 
are  some  cases  in  which  there  has  been  a  notable  exacer- 
bation of  pain  in  the  days  preceding  the  rupture;  the 
patients  have  explained  to  me  that  the  body  or  side  felt 
stiff  and  sore;  that  laughing  or  stretching,  as  in  reaching 
up    to    a    high    shelf,    caused   great   discomfort.     These 


Perforation  245 

inaugural  symptoms  of  perforation  are  important,  and 
if  the  practitioner  chances  to  hear  of  them  from  a  patient 
whom  he  knows  to  have  an  ulcer  in  the  stomach,  he 
could  accept  them  as  undoubted  evidence  of  impending 
perforation.  In  my  own  experience  perforation  of  an 
ulcer  has  not  occurred  without  a  previous  history  of 
duodenal  ulcer  being  given.  The  pain  is  sudden  in 
onset,  and  may  be  followed  rapidly  by  vomiting  and 
prostration.  The  abdomen  on  examination  is  every- 
where tender.  A  careful  examination  may  reveal  an 
especially  tender  and  resistant  area.  A  patch  2  or  3 
inches  in  diameter  may  be  excessively  sensitive,  and 
on  palpation  it  may  seem  as  though  a  flat,  hard  disc 
has  been  inserted  in  the  abdominal  wall. 

The  symptoms  abate  slowly.  The  pulse  does  not 
increase,  its  character  improves,  vomiting  ceases,  the 
abdomen,  which  was  hard  and  retracted  at  the  first, 
may  become  supple  except  at  the  one  spot,  or  it  may  be 
a  little  distended,  and  free  fluid  may  possibly  be  recog- 
nised. The  patient's  condition  may  indeed,  at  this 
stage,  be  so  satisfactory,  as  compared  with  the  initial 
condition,  that  the  diagnosis  may  be  in  doubt.  If, 
indeed,  morphine  has  been  given,  as  it  still  very  often 
i-,  in  repeated  doses,  the  aspect  of  the  patient  may  be 
little  different  from  the  normal.  It"  no  operation  is 
practised  at  this  time,  there  are  three  directions  which 
affairs  may  take:  either  a  periduodenal  abscess  may 
form,  or  a  secondary  rupture  into  the  general  peri- 
toneum may  occur,  or  the  adhesion  of  the  ulcer  to  the 
abdominal  wall  or  liver  or  pancreas  maj  become  firmer, 
the    acute    inflammatory    conditions    subside,    and    the 


246  Duodenal  Ulcer 

patients  live  for  many  years  with  a  chronic  ulcer  whose 
base  is  formed  by  one  of  the  structures  already  men- 
tioned. Of  the  three,  I  believe  the  last  to  be  the  most 
common. 

Differential  Diagnosis. — The  conditions  likely  to  be 
confused  with  subacute  perforation  of  the  stomach  or 
duodenum  are  few.  The  chief  difficulty  in  diagnosis 
arises  in  discriminating  a  subacute  perforation  near  the 
pylorus  from  a  condition  of  cholecystitis.  In  both, 
there  is  pain,  sudden  in  onset,  severe  and  possibly 
colicky;  in  neither  is  there  any  general  invasion  of  the 
peritoneum;  in  both  a  localised  peritonitis  with  a  tender 
resistant  area  is  recognised.  The  previous  history  may 
afford  a  clue,  but  is  not  likely  to  do  so.  Lund  ("  Boston 
Med.  and  Surg.  Journ.,"  1905,  i,  516)  gives  notes  of  a 
case  in  which  it  was  considered  possible  that  a  perfor- 
ation of  a  malignant  growth  in  the  colon  had  occurred. 

Treatment. — If  the  patient  is  seen  at  the  time  of  the 
onset  of  perforation,  I  think  there  can  be  no  hesitation 
in  advising  instant  operation.  In  the  first  place,  accu- 
rate and  unequivocal  discrimination  between  acute 
and  subacute  perforation  cannot  be  made,  and  by  delay 
valuable  time  may  be  lost.  Moreover,  though  it  is  true 
that  many  of  the  subacute  cases,  with  rest  in  bed,  absten- 
tion from  food,  and  so  forth,  may  progress  to  the  chronic 
stage,  there  are  indubitably  other  possibilities  which, 
when  reckoned  with,  make  early  operative  treatment 
the  safe  and  prudent  course.  In  all  the  cases  I  have 
seen  in  the  early  stage  I  have  operated  and  have  cleared 
the  ulcer  of  adhesions,  infolded  it,  and  occasionally 
sutured  a  flap  of  omentum  over  the  line  of  stitches. 


Perforation  247 

I  did  this  at  first  because  I  did  not  distinguish  between 
the  acute  and  the  subacute  cases;  I  did  it  subsequently 
because  it  had  seemed  to  be  the  right  course  to  have 
pursued  in  the  early  cases.  Dr.  Lund  has,  however, 
suggested  ("Boston  Med.  and  Surg.  Journ.,"  1905,  i, 
516)  that  since  the  perforation  is  already  sealed  off, 
there  is  no  need  to  expose  and  then  close  the  rent  afresh, 
and  that,  accordingly,  the  proper  course  is  to  perform 
gastroenterostomy  forthwith,  leaving,  if  possible,  the 
ulcer  and  its  secure  barriers  untouched. 

CHRONIC  PERFORATION 
In  chronic  perforation  of  the  duodenum  the  ulcer 
destroys  the  coats  of  the  bowel  in  a  very  leisurely  manner; 
as  the  serous  coat  of  the  gut  is  reached  a  protective 
barrier  of  lymph,  probably  reinforced  by  the  omentum, 
is  raised  so  as  to  guard  against  a  rupture  into  the  general 
peritoneal  cavity.  By  the  time  the  last  thin  layer  of 
the  duodenal  wall  is  destroyed  the  contents  of  the  bowel 
are  prevented  altogether  from  escaping,  or  are  restricted 
to  a  very  limited  area  surrounded  by  recently  formed 
adhesions.  In  these  circumstances  a  cavity  of  gradu- 
ally increasing  size  develops  and  the  contents  become 
purulent.  A  periduodenal  abscess  results.  There  are 
probably  other  though  less  numerous  cases  in  which  the 
condition-  are  different  from  this.  The  perforation  may 
perhaps  occur  suddenly,  and  no  restrictive  barriers  are 
present,  but  the  perforation  is  of  so  very  minute  a  size 
or  the  duodenum  is  so  empty  thai  the  leakage  is  exces- 
sively small.  The  bastion  of  lymph  is  then  thrown  out, 
.mil  all  subsequent  leakage  is  limited  to  an  area  to  which 


248  Duodenal  Ulcer 

the  bounds  have  already  been  firmly  set.  In  this  case, 
too,  a  periduodenal  abscess  results.  In  both,  the  com- 
munication with  the  duodenum  may  be  shut  off  com- 
pletely, or  may  be  closed  in  such  manner  as  to  give  way 
when  the  abscess  has  been  opened.  A  duodenal  fistula 
then  results. 

When  an  abscess  has  formed  around  the  perforation 
in  the  duodenum,  it  increases  slowly  in  size  and  event- 
ually may  terminate  by  rupture  in  one  of  several  direc- 
tions. Krauss  in  his  monograph  ("Das  perforirende 
Geschwiir  im  Duodenum,"  Berlin,  1865,  August  Hirsch- 
wald,  p.  33)  first  called  attention  to  this  condition  and  as- 
serted that  the  abscess  always  burrowed  in  a  backward  di- 
rection. He  quotes  three  cases  in  which  this  had  been  ob- 
served. The  first  (Forster:  "Wiirzburg.  med.  Zeitsch.," 
1 861,  ii,  162)  occurred  in  a  student  nineteen  years  of 
age,  who  had  suffered  for  some  time  from  pain  and 
fullness  in  the  stomach  region  one  to  two  hours  after  a 
meal,  and  who  died  rapidly  after  the  sudden  onset  of 
acute  peritonitis.  At  the  autopsy  there  were  found 
two  perforating  ulcers  of  the  duodenum:  one  on  the 
anterior  surface,  which  penetrated  into  the  general 
peritoneal  cavity;  one  on  the  posterior  surface,  which 
communicated  with  an  abscess  which  had  encroached 
upon  the  retroperitoneal  space,  and  had  burrowed 
along  the  greater  vessels  until  it  reached  the  neck, 
where  the  skin  was  thin,  emphysematous,  and  reddened. 
The  periduodenal  abscess  was  pointed  in  the  neck. 
In  the  second  case  the  abscess  pointed  between  the 
seventh  and  eighth  ribs  posteriorly;  and  in  the  third  a 
swelling  hard   and    lender   lay  at  the   tip  of  the  right 


Perforation  249 

scapula.  In  the  "London  Medical  Gazette"  (1829, 
iii,  43)  Streeton  records  a  case  of  chronic  duodenal 
perforation  occurring  in  a  phthisical  woman  of  thirty- 
nine.  A  hard  painful  tumour  formed  at  the  angle  of 
the  right  scapula  and  burst;  later  on  a  second  abscess 
a  little  in  front  of  this  formed  and  discharged.  After  a 
short  time  the  gastric  contents  escaped  from  the  sinus 
within  five  minutes  of  ingestion.  At  the  autopsy  a 
perforating  ulcer  at  the  junction  of  the  first  and  second 
portions  of  the  duodenum  was  found,  and  from  this  a 
fistula  led  to  the  opening  on  the  surface  of  the  chest. 

Almost  any  direction  may  be  taken  by  the  pus  in  its 
insidious  progress.  Hoffman  ("Yirch.  Archiv,"  1862, 
xlii,  218)  related  the  case  of  a  woman,  aged  sixty-three, 
who  suffered  from  a  chronic  perforation  of  the  duodenum. 
A  circumscribed  peritonitis  resulted  and  pus  formed. 
The  common  duct  was  compressed  to  closure  and  jaun- 
dice followed.  The  gall-bladder  was  penetrated,  so 
that  bile  escaped  into  the  abscess  cavity  and  thence  into 
the  duodenum,  through  the  aperture  of  perforation. 
The  purulent  material  in  the  abscess  tracked  downwards 
along  the  ascending  colon  to  the  iliac  io>>a,  and,  there 
collecting,  burst  at  lasl  into  the  caecum.  A  case  is 
recorded  by  Perry  and  Shaw  (Case  211,  p.  270)  in  which 
a  chronic  perforation  of  the  duodenum  led  to  an  absi 
which  occupied  both  iliac  fossa?  and  the  pelvis.  Four 
incisions  were  made,  in  the  loin  and  iliac  fossa  ol  both 
>ide>,  and  pus  was  drained  therefrom  for  >i\  months, 
until  the  patient  died. 

An  interesting  case  is  recorded   by   Meunier    "Hull. 
.   Anat.."    [893,  Ixviii,    (.87).      The  patient  was  a  man 


250  Duodenal  Ulcer 

aged  sixty-one,  who  suffered  from  indigestion  for  months 
before  admission  to  hospital,  where  he  was  found  to 
have  a  dilated  and  hypertrophied  stomach  and  a  tumour 
(neoplasm?)  beneath  the  right  costal  margin.  He  died 
greatly  wasted  from  gradual  inanition  and  exhaustion. 
At  the  postmortem  examination  an  abscess  cavity  was 
found  on  the  under  surface  of  the  liver;  it  was  cir- 
cumscribed and  its  walls  were  of  great  thickness.  It 
contained  a  purulent  fluid  and  was  traversed  by  the  duo- 
denum, which  was  completely  severed,  as  though  divided 
by  scissors.  The  point  of  division  was  3  cm.  beyond 
the  pylorus.  I  can  find  no  report  in  the  literature  of 
so  great  a  destruction  of  the  duodenal  wall  by  ulcer  as 
is  described  and  figured  in  this  case. 

The  abscess  which  forms  may  reach  the  anterior 
abdominal  wall.  Bucquoy  ("Arch.  Gen.  de  Med.," 
1887,  i,  414  et  seq.)  records  the  case  of  a  woman,  thirty- 
two  years  of  age,  who  had  suffered  for  a  long  period 
from  symptoms  suggestive  of  ulcer  of  the  duodenum 
Finally,  after  a  severe  attack  of  colicky  pain  a  tumidity, 
at  first  dull,  but  later  tympanitic,  developed  on  the  right 
side  of  the  abdomen.  An  abscess  opened  close  to  the 
umbilicus  and  discharged  intestinal  contents  until  the 
patient's  death.  Luneau  ("Bull.  Soc.  Anat.,"  1870, 
xv,  429)  gives  details  of  the  case  of  a  man  of  fifty-eight 
who  had  suffered  from  indigestion  and  hiematemesis 
for  some  weeks.  Two  or  three  small  abscesses  formed 
in  the  anterior  abdominal  wall,  burst,  and  healed.  Three 
months  later  a  large  abscess  formed  and  burst  "in  the 
gall-bladder  region."  The  half-digested  contents  of  the 
stomach  escaped  from  the  fistula  which  remained,  and 


Perforation  2CI 

continued  to  do  so  until  the  patient's  death  from  inani- 
tion eighteen  months  later.  At  the  postmortem  exami- 
nation a  large  irregular  abscess  cavity  was  found  which 
extended  upwards  above  the  liver,  and  occupied  a  large 
space  in  the  abdominal  wall  in  front  of  the  parietal 
peritoneum. 

It  is  clear  from  this  brief  record  of  cases  that  an  abscess 
which  forms  as  a  result  of  the  languid  perforation  of  the 
duodenal  wall  may  burrow  in  any  direction  and  may 
reach  the  surface  of  the  body  in  almost  any  near  region. 
The  fistula  which  then  results — -the  "external  duodenal 
fistula,"  as  it  may  be  called — gives  passage  to  a  greater  or 
smaller  quantity  of  fluid  according  to  its  size  and  posi- 
tion. The  escape  of  this  fluid  deprives  the  body  of  a 
great  part  of  the  material  upon  which  it  depends  for 
sustenance,  and  inanition  gradually  becomes  pronounced. 
Death  comes  at  last  from  sheer  deprivation  of  food — - 
starvation.  A  fatal  termination  is  only  to  be  avoided 
by  the  early  adoption  of  surgical  treatment  on  the 
lines  to  be  presently  discussed. 

Treatment. — The  treatment  of  a  periduodenal  abscess 
is  carried  out  by  the  same  means  as  hold  good  for  other 
localised  collections  of  pus  in  the  abdomen.  The 
matter  is  evacuated  and  drainage  instituted.  In  some 
case--  this  will  suffice;  the  cavity  gr<>\\  -  by  degrees  ^mailer 
and  smaller  and  eventually  closes  altogether.  Hut  in 
other  cases,  unhappily  more  numerous,  the  opening 
of  the  abscess,  or  it^  spontaneous  evacuation,  results 
in  the  formation  of  a  fistula  for  which  surgical  treat- 
merit  is  urgently  needed  if  lite  is  to  1m-  saved.  The 
method   of    treatment    which    was    suggested    by    Berg 


i^z  Duodenal  Ulcer 

("Cent.  f.  Chir.,"  1903,  556)  consists  in  the  performance 
of  gastro-enterostomy,  together  with  occlusion  of  the 
pylorus.  It  has  been  shewn  by  the  work  of  Kelling 
"Arch.  f.  klin.  Chir.,"  1906,  lxx,  289)  that  if  gastro- 
enterostomy is  done  when  the  pylorus  is  patent,  all 
the  food  continues  to  pass  by  the  duodenum,  and  that 
as  a  rule  none,  but  at  the  most  a  very  little,  of  the  food 
escapes  through  the  new  opening.  That  this  experi- 
mental observation  holds  good  in  the  case  of  a  man 
or  woman  afflicted  with  an  organic  lesion  of  the  stomach 
is  now  a  generally  accepted  belief.  Berg's  suggestion 
was  that  a  new  outlet  should  be  effected  to  the  stomach 
by  the  performance  of  gastro-enterostomy,  and  that 
the  food  should  be  compelled  to  pass  along  this  new 
path;  this  is  secured  by  closing  the  original  outlet  by 
sutures  or  by  a  tape  tied  round  the  pylorus.  Berg 
("Annals  of  Surgery,"  1907,  xlv,  721),  in  a  further 
article,  mentions  that  he  had  lost  one  patient  in  three 
days  after  the  establishment  of  a  duodenal  fistula. 
He  then  records  in  detail  two  cases  in  which  he  adopted 
his  own  proposal,  performing  gastro-enterostomy  and 
occlusion  of  the  duodenum.  Both  patients  died,  though 
they  lived  long  enough  to  demonstrate  the  soundness 
of  the  operative  procedure  which  had  been  followed. 
The  following  is  the  report  of  his  second  case: 

"Chas.  A.  \\\,  a  native  of  England,  fifty-two  years  old, 
and  a  mechanic  by  occupation,  was  seen  by  the  writer  with  Dr. 
Matthews  on  February  11,  1906.  For  two  years  prior  to  the 
present  illness  he  had  suffered  with  attacks  of  vomiting,  not 
associated  with  the  taking  of  food.  On  February  1,  1906, 
the  patient  was  suddenly  seized,  while  at  work,  with  severe 
abdominal  cramps,  which  subsequently  localised   themselves 


Perforation  253 

to  the  right  iliac  fossa.  He  vomited  at  the  onset,  but  had  no 
fever  or  chills.  His  bowels  were  constipated.  With  rest 
in  bed  and  local  applications  of  ice,  he  improved,  and  three  days 
later  got  up.  Twenty-four  hours  before  I  saw  him,  while  he 
was  sitting  by  the  stove,  he  was  again  suddenly  seized,  after 
a  severe  sneezing  spell,  with  acute  abdominal  pain  and  vom- 
iting. The  pain  was  most  severe  just  below  the  free  border 
of  the  ribs  on  the  left  side.  On  physical  examination,  the 
heart  and  lungs  were  normal.  The  abdominal  wall  was  of 
board-like  rigidity  and  did  not  move  with  respiration.  The 
liver  dullness  was  replaced  by  dull  tympanitic  resonance. 
There  was  dullness  in  both  flanks,  which  did  not,  however, 
shift  with  change  in  the  patient's  position.  There  was  an  area 
of  dullness  in  the  right  hypochondrium  which  corresponded  to 
an  ill-defined  mass  about  the  size  of  a  teacup  saucer.  His 
temperature  was  ioo°,  his  pulse  108.  Diagnosis:  Ruptured 
duodenal  ulcer,  with  encapsulated  periduodenal  exudate. 
Immediate  laparotomy  was  proceeded  with  at  Mt.  Sinai 
Hospital.  An  incision  was  made  over  the  mass  through  the 
right  rectus  muscle.  Immediately  on  incising  the  peritoneum 
fresh  adhesions  were  encountered  to  the  right  of  the  suspensory 
ligament  of  the  liver  and  extending  downwards  to  the  umbilical 
region.  The  adhesions  were  carefully  separated  and  the  peri- 
toneal surfaces  thus  exposed  at  once  protected  by  gauze 
packing-.  On  separating  the  adhesions  towards  the  liver  a 
large,  foul-smelling  gaseous  abscess  containing  about  a  pint 
of  creamy  pus  was  entered  into  and  evacuated.  After  the  pus 
was  removed  a  perforation  was  found  on  the  anterior  surface 
of  the  first  part  of  the  duodenum,  about  the  size  of  a  pea, 
with  gangrenous  edges;  the  surrounding  peritoneal  surfaces 
of  the  stomach  and  duodenum  were  covered  with  necrotic 
fibrin  and  pus.  Alter  this  latter  was  carefully  removed  the 
perforation  was  closed  with  three  layers  of  Lemberl  sutures 
pi, iced  in  the  vertical  axis  of  the  duodenum.  The  absi 
cavity  was  drained  and  the  abdominal  wound  closed  with 
layer*  suture  down  \<>  tin  emergence  of  the  drains.     The  patient 

re tried    well    from    '.he   Operation.       The    highesl     temper, Hurt' 

and   pulse   tor  the  following  week  were   100.60  and    104   r< 
spectively. 


254  Duodenal  Ulcer 

"No  drink  or  food  was  allowed  by  mouth  for  five  days, 
rectal  nourishment  and  saline  subcutaneous  infusion  being 
used  to  replace  them.  On  February  18th,  i.  e.,  seven  days 
after  the  operation,  there  was  noticed  for  the  first  time  an 
escape  of  gastric  contents  and  bile  from  the  drainage  openings. 
Recognising  at  once  the  fact  that  we  had  to  deal  with  a  duo- 
denal fistula  that,  on  account  of  the  changed  character  of  its 
surrotinding  peritoneal  surfaces,  could  not  be  closed  by  suture, 
and  profiting  by  the  sad  experience  gained  in  previous  cases 
of  duodenal  fistula,  in  which  death  from  inanition  and  ex- 
haustion followed  after  forty-eight  to  seventy-two  hours,  I 
at  once  proceeded  to  carry  out  the  suggestion  I  had  made 
in  1903,  viz.,  gastrojejunostomy  with  pyloric  exclusion. 
A  posterior  gastrojejunostomy  without  a  loop  by  the  suture 
method  was  accordingly  made,  but  instead  of  occluding  the 
pylorus,  I  sewed  up  again  the  opening  in  the  duodenum, 
hoping  thereby  to  avoid  all  danger  from  a  possible  cutting 
through  of  the  occluding  pyloric  suture. 

"The  patient  bore  this  operation  well,  and  for  two  days 
there  was  no  escape  of  gastric  or  duodenal  contents.  Then 
the  suture  line  in  the  duodenum  again  gave  wTay  and  there  was 
a  renewal  of  the  leakage.  It  was  noticed  that  after  t In- 
patient took  some  milk  by  mouth  there  would  be,  within  ten 
minutes,  a  discharge  of  milk  from  the  duodenal  fistula,  and 
within  fifteen  to  twenty  minutes  more,  approximately  all 
the  milk  that  had  been  ingested  had  escaped  from  the  duodenal 
opening.  The  wound  in  which  the  fistulous  opening  lay  was 
so  infected  that  I  now  hesitated,  from  fear  of  infecting  the 
peritonea]  cavity,  to  expose  the  pylorus  sufficiently  through 
it,  in  order  to  enable  me  to  pass  an  occluding  ligature  around 
it.  I  therefore  made  several  further  attempts  to  close  the 
duodenal  opening  by  suture,  but  each  time  after  twenty-four 
hours  the  sutures  would  cut  out  and  leave  the  opening  ;is 
before;  and  each  time  the  duodenum  was  open,  whatever  was 
taken  into  the  stomach  would  practically  all  be  discharged 
through  it  within  fifteen  to  twenty  minutes  after  it  was  in- 
gested. On  February  28th,  i.  e.,  ten  days  after  the  gastro- 
jejunostomy, I  was  compelled  by  the  progressive  deterioration 
of  the  patient  to  brave  the  danger  of  a  peritonitis,  and  to 


Perforation  255 

mobilise  the  pylorus  and  surround  it  by  an  occluding  ligature, 
using  for  the  latter  a  broad  piece  of  tape.  This  was  passed 
around  the  pylorus  snugly  enough  to  effect  approximation 
of  its  walls,  but  with  no  constriction  of  the  parts,  and  held 
in  place  by  a  silk  suture,  the  knot  of  which  rested  on  the  tape 
and  not  on  the  pylorus  itself,  thereby  avoiding  pressure  from 
it  upon  the  pylorus. 

"Immediately  after  this  operation  the  patient  was  given 
6  ounces  of  milk  and  water.  There  was  no  leakage,  nor  was 
there  any  further  leakage  from  the  fistula  during  the  next 
twenty-four  hours.  The  patient's  strength,  however,  was 
so  much  exhausted  by  the  intermittent  but  continued  dis- 
charge of  chyme  and  duodenal  contents  that  he  did  not  rally 
from  this  last  operation  and  succumbed  the  next  day. 

"Post-mortem  examination  revealed  a  gastro-jejunal  ori- 
fice patent  for  three  fingers,  and  a  ruptured  duodenal  ulcer." 

This  procedure  would,  I  think,  be  improved  by  merely 
infolding  the  pylorus,  or  the  stomach  in  front  of  the 
pylorus,  by  superimposed  sutures  applied  in  the  same 
manner  as  when  an  ulcer  is  infolded  and  buried. 

The  following  case  of  duodenal  fistula  occurred  in 
the  practice  of  my  colleague,  Mr.  Lawford  Knaggs,  who 
has  very  kindly  given  me  details  of  the  history  for 
publication: 

Stella  R.,  aged  seventeen,  was  admitted  to  the  Leeds 
General  Infirmary  on  October  27,  1906.  She  had  previously 
been  an  in-patient  from  September  27  to  October  30,  1005. 
for  cystitis,  from  which  she  had  quite  recovered.  At  the 
time  gonocoi  ci  were  said  to  be  present  in  the  urine. 

Three  months  before  her  admission  under  Dr.  Harrs  she 
began  to  have  attacks  of  sickness  and  diarrhoea,  and  passed 
a  little  blood.  The  sickness  came  on  after  taking  food,  and 
she  would  usually  vomil  once  a  day,  bul  occasionall)  she 
would  go  for  >ix  or  seven  days  without  doing  so.  She  also 
had  pain  which  came  on  a  quarter  of  an  hour  after  a  meal, 
lasted  about  an  hour,  and  went  away  gradually.     Tin-  con- 


256  Duodenal  Ulcer 

dition  persisted  until  the  week  before  admission,  when  she 
became  worse.     She  had  lost  flesh. 

On  admission  nothing  abnormal  was  found  on  examination 
of  the  abdomen  and  nothing  definitely  wrong  in  the  chest, 
though  a  slight  taint  in  the  family  history,  nocturnal  per- 
spirations, and  a  rather  rapid  pulse  suggested  the  possibility 
of  tubercle.     The  urine  was  normal. 

At  first  the  pain  and  sickness  disappeared,  though  the  pa- 
tient was  put  upon  ordinary  diet,  but  about  November  7th 
she  complained  of  pain  in  the  right  hypochondriac  region  and 
the  temperature  rose  and  gradually  assumed  an  intermittent 
type.  On  December  12th  a  mass  was  noticed  in  the  right 
.loin,  and  the  right  knee  was  partially  flexed  and  drawn  up. 
On  the  15th  there  was  exquisite  tenderness  at  the  bottom  of 
the  right  side  of  the  chest.  On  January  9,  1907,  under 
anaesthesia,  the  swelling  on  the  right  side  of  the  abdomen 
was  hard  and  could  be  felt  to  disappear  under  cover  of  the 
ribs  It  was  largest  just  before  it  did  so.  Its  boundaries 
were  vague. 

On  March  14th  she  was  transferred  to  the  surgical  side, 
where  the  condition  was  regarded  as  a  subacute  suppuration 
under  the  psoas  sheath,  producing  flexion  of  the  hip  and 
lordosis. 

On  January  23d  an  incision  was  made  in  the  right  loin 
through  muscles  that  were  very  firm  from  inflammatory 
infiltration.  An  abscess  was  opened  by  manipulation  with 
the  finger  through  an  indurated  mass,  and  alone  an  ounce  of 
pus  escaped  and  a  drainage-tube  was  inserted. 

On  March  6th,  drainage  not  being  satisfactory,  the  resulting 
sinus  was  opened  up,  and,  owing  to  the  disappearance  of  the 
induration,  a  considerable  cavity  could  be  explored.     It  was" 
still  regarded  as  situated  under  the  psoas  fascia. 

On  March  25th  a  portion  of  orange  pulp  was  noticed  on  the 
dressings,  and  it  was  then  realised  that  the  curious  odour  of 
the  discharge  which  had  been  noticed  for  several  days  was  due 
to  gastric  fluids.     There  was  no  trace  of  bile  or  of  faeces. 

Charcoal  made  its  appearance  on  the  dressings  four  hours 
after  it  had  been  taken.  She  remained  an  in-patient  till 
April  16th,  when  the  wound  had  contracted  to  the  drainage- 


Perforation  257 

tube  track,  but  there  was  still  a  considerable  discharge,  having 
the  peculiar  odour  just  referred  to,  and  in  which  evidence  of 
fluid  food  was  frequently  observed.  She  was  now  sent  home, 
in  the  hope  that  the  communication  that  existed  with  the 
stomach  or  duodenum  would  gradually  close. 

She  was  readmitted  on  June  13th.  Xo  alteration  in  the 
amount  or  character  of  the  discharge  from  the  sinus  had 
taken  place,  and  whenever  charcoal  was  swallowed,  some  of  it 
came  away  from  the  sinus  in  from  two  to  five  hours.  Occa- 
sionally bubbles  of  gas  escaped,  and  the  patient  stated  that  a 
"rush"  of  discharge  would  occur  when  she  was  actually 
masticating  her  food. 

On  July  3d  the  abdomen  was  opened.  Considerable  evi- 
dence of  past  inflammation  was  found  in  the  neighbourhood 
of  the  duodenum.  The  adhesions  which  existed  between  the 
under  surface  of  the  liver,  the  duodenum,  the  pylorus,  and 
the  transverse  mesocolon  were  numerous  but  not  tough. 
Their  separation  before  the  duodenum  could  be  examined 
caused  some  trouble.  The  only  trace  of  ulcer  that  could  be 
detected  was  at  the  posterior  surface  of  the  pylorus.  The 
finger  pressing  upon  the  anterior  wall  was  felt  to  impinge 
upon  a  depression  as  big  as  a  threepenny  piece.  This  part  of 
the  pylorus  was  movable  to  a  certain  extent.  The  stomach 
was  quite  healthy.  A  posterior  gastro-enterostomy  was 
performed,  and  then  the  pylorus  was  infolded  by  two  rows 
of  Lembert  sutures  about  \x/i  inches  long,  one  over  the  other. 
In  this  way  the  pyloric  end  of  the  stomach  was  coin  cried 
into  a  solid  roll  a  little  thicker  than  the  thumb. 

After  the  operation  the  >our  odour  at  once  disappeared  from 
the  discharge  and  no  more  particles  of  food  were  ever  seen. 
The  next  day  bile-,  which  had  never  escaped  before,  was  mixed 
with  the  discharge,  and  persisted  for  about  a  week,  gradually 
diminishing. 

The  patienl  left  tin-  hospital  <>n  Augusl  2  ».  1007,  when  the 
discharge  from  the  lumbar  sinus  had  diminished  considerably. 
The  charcoal  tesl  was  now  always  negative.  A  small  sinus 
persisted  for  a  long  time,  but  had  finally  closed  in  April, 
[908.     Ih-r  general   condition   alter   the  abscess  cavity   was 

17 


258  Duodenal  Ulcer 

thoroughly  drained  was  always  satisfactory,  and  for  the  last 
year  or  more  she  has  been  the  picture  of  health. 

The  following  is  a  list  of  my  cases  of  perforating  duo- 
denal ulcer. 

Case  i. — April,  1900;  male,  aged  forty-four.  Symptoms 
had  been  present  for  eighteen  months;  the  chief  of  them  was 
pain  two,  three,  or  four  hours  after  food.  Blood  had  been 
observed  when  the  patient  vomited;  vomiting  was  frequent 
but  irregular.  There  was  no  melaena.  On  the  25th,  while 
in  the  Infirmary,  the  man  became  suddenly  worse ;  pain  came 
on  acutely  in  the  whole  abdomen.  Distension  and  rigidity 
were  soon  observed.  Collapse  was  pronounced.  The  res- 
pirations were  28  and  the  pulse  was  128.  A  diagnosis  of 
perforating  ulcer  Avas  made  and  the  abdomen  was  opened. 
The  ulcer  was  found  at  the  beginning  of  the  second  part  of 
the  duodenum;  its  diameter  was  about  three-quarters  of  an 
inch.  After  stitching  the  ulcer  up,  the  gut  was  narrowed  to 
at  least  half  its  diameter.  A  gastro-enterostomy  with  the 
aid  of  a  Murphy  button  was  therefore  performed.  The 
patient  never  rallied  from  his  collapse.  Time  of  operation 
after  perforation  about  twenty-six  hours. 

CASE  2. — June  18,  1901;  male,  aged  twenty-five.  The 
patient,  a  sturdy,  robust  labourer,  stated  that  for  about  four 
weeks  before  admission  he  had  suffered  from  indigestion  and 
vomiting.  On  the  18th,  while  climbing  a  ladder,  he  was  sud- 
denly seized  with  intense  abdominal  pain.  He  was  seen  at 
once  by  a  medical  man  who  happened  to  be  near  and  w;b 
sent  to  the  Infirmary.  He  was  then  profoundly  collapsed. 
Breathing  was  quick  and  short;  his  pulse  was  128;  the  ab- 
domen was  rigid  and  unyielding.  A  diagnosis  of  perforated 
ulcer  was  made.  At  the  operation  a  perforation  equal  in 
diameter  to  a  No.  8  or  No.  9  catheter  was  found  in  the  duo- 
denum, one  inch  from  the  pylorus.  The  ulcer  was  stitched  and 
the  abdomen  was  cleansed  and  drained.  The  patient  re- 
covered. Time  of  operation  after  perforation  three  hours 
fifty  minutes.     The  patient  was  quite  well  in  January,  1908. 

Case  3. — April   20,    1902;    female,   aged   seventeen.     For 


Perforation  259 

several  weeks  she  had  slight  indigestion  and  epigastric  pain, 
but  not  in  sufficient  severity  to  send  her  to  a  medical  man. 
On  the  night  of  April  19th  at  9  p.  m.  she  had  a  sudden  attack 
of  acute  epigastric  pain.  Morphine  was  given.  She  was  seen 
at  7  A.  M.;  the  abdomen  was  very  rigid  and  rather  tender, 
especially  over  the  gall-bladder.  She  had  vomited  once. 
The  pulse  was  112.  Respiration  was  very  shallow.  At  the 
operation  an  ulcer  was  found  to  have  perforated  on  the  an- 
terior surface  of  the  duodenum,  about  three-quarters  of  an 
inch  from  the  pylorus.  There  was  some  fluid  above  the 
stomach.  The  ulcer  was  closed  by  suture  and  the  peritoneum 
was  cleansed  by  wiping  with  swabs  wet  with  sterile  salt 
solution.  There  was  no  lavage  and  no  drainage.  The 
patient  recovered.  Time  of  operation  after  perforation  about 
ten  hours.  Gastro-enterostomy  had  subsequently  to  be 
performed  on  account  of  stenosis.  The  patient  was  quite 
well  in  1909. 

Case  4. — March  26,  1903;  male,  aged  twenty-eight.  Had 
suffered  from  "flatulent  indigestion,"  but  was  otherwise  quite 
well  up  to  9  P.  M.  on  March  25,  1903.  At  that  time  he  was 
straining  heavily  at  work  and  suddenly  felt  a  pain  in  the  upper 
part  of  the  abdomen  which  caused  him  to  feel  faint.  The 
pain  lessened  considerably  in  about  an  hour,  but  he  then  felt 
"as  if  he  had  been  winded"  by  a  blow  on  the  epigastrium;  the 
abdomen  became  slightly  distended  and  very  rigid  ;  tenderness 
was  especially  noticed  in  the  upper  part  on  the  right  side  and 
downwards  towards  the  appendix.  A  diagnosis  of  duodenal 
ulcer  was  made.  The  abdomen  was  opened  through  the  righl 
rectus.  There  was  a  large  quantity  of  loose  flocculent  lymph 
surrounding  a  perforation  in  the  firsl  part  of  the  duodenum. 
The  ulcer  was  stitched  up  by  two  continuous  sutures.  The 
patient  recovered.  Was  senl  by  Dr.  Oldfield.  Time  after 
perforation  thirty-one  hours.  Subphrenic  abscess  followed 
on  twentieth  day  and  was  opened;  subsequent  progress  good. 
Six  months  later  (November,  [903)  symptoms  ascribed  i"  .1 
cerebral  abscess  developed  and  the  patient  died.  No  opera 
tion  was  performed  and  no  post-mortem  examination  was 
obtained. 

Case   5.     December   27,    [903;    female,   aged    seventeen. 


260  Duodenal  Ulcer 

She  had  always  been  pale  and  an  emic  and  for  twelve  months 

had  complained  of  indigestion  and  occasional  vomiting. 
Illness  commenced  suddenly  four  days  before  admission  with 
pain  in  the  right  side  and  across  the  abdomen.  There  was 
vomiting.  At  the  operation  perforated  duodenal  ulcer  was 
found.  An  incision  was  made  in  the  right  flank;  offensive 
pus  was  found.  Tubes  were  inserted.  The  patient  recovered 
and  is  now  in  sound  health.      (A  case  of  subacute  perforation.) 

Case  6. — March  24,  1904;  female,  aged  twenty-five.  She 
had  had  indigestion  for  twelve  years.  For  many  years  she 
had  had  acid  eructations  and  for  the  last  two  years  had 
vomited  after  food.  She  had  had  many  severe  attacks  of 
pain  in  the  epigastrium.  Four  days  prior  to  admission,  and 
again  one  day  before,  she  had  attacks,  but  not  any  more 
acute  than  many  she  had  had  previously.  During  the  last 
three  years  her  weight  had  dropped  from  9  stone  to  5  stone 
8/4  pounds.  At  the  operation  there  was  found  to  be  a  perfora- 
tion of  the  size  of  a  small  pea  in  the  upper  part  of  the  first 
portion  of  the  duodenum.  The  ulcer  was  of  about  the  size 
of  a  half-crown.  There  was  a  little  local  plastic  peritonitis, 
but  no  general  infection.  The  perforation  was  closed  by 
Lembert's  sutures  and  a  posterior  gastro-enterostomy  was 
performed.     The  patient  recovered. 

Case  7. — May  11,  1904;  male,  aged  twenty-two.  He  has 
been  quite  healthy  up  to  the  beginning  of  April,  1904,  when 
he  felt  an  acute  pain  in  the  abdomen.  This  only  lasted  a 
few  minutes  and  then  passed  off;  subsequently  he  had  daily 
discomfort  one  to  two  hours  after  food,  belching,  fullness,  and 
acidity.  Three  weeks  later  he  was  again  seized  with  extremely 
acute  abdominal  pain.  Within  three  minutes  he  was  in  a 
state  of  complete  collapse.  The  pain  was  most  severe  in  the 
epigastric  region  at  first,  later  it  was  acute  in  the  lower  part, 
and  in  two  or  three  days  it  settled  in  the  right  iliac  region. 
He  vomited  at  the  beginning,  not  again  later.  There  was 
slight  constipation.  He  recovered  very  rapidly  and  went 
out  for  a  stroll  on  the  ninth  day.  On  symptoms  of  a  similar 
kind  again  coming  on,  operation  was  advised.  At  the  opera- 
tion an  incision  was  made  over  the  appendix.  The  appendix 
was  found  lying  along  the  outer  side  of  the  ascending  colon 


Perforation  261 

and  adherent  in  all  its  length.  It  was  removed.  The  hand 
passed  up  into  the  liver  region  felt  numerous  adhesions.  A 
second  incision  was  made  over  the  gall-bladder.  Numerous 
adhesions  of  the  gall-bladder  to  the  liver  and  duodenum  were 
separated,  also  a  very  strong  one  between  the  duodenum  and 
the  under  surface  of  the  liver.  On  examining  the  surface  of 
the  duodenum  thus  bared  a  minute  perforation  was  seen. 
This  was  occluded  by  Lembert's  sutures  and  the  abdomen 
was  closed.     The  patient  recovered. 

Case  8. — September  9,  1904  (6  p.  m.);  male,  aged  forty. 
The  patient  was  admitted  into  the  Leeds  General  Infirmary 
with  a  history  of  having  had  a  large  barrel  fall  on  the  left  side 
of  his  abdomen  just  below  the  umbilicus  two  hours  previously. 
The  following  history  was  obtained  from  the  wife  (subsequent 
to  the  operation) :  He  had  been  in  poor  health  for  some 
time  back,  having  been  under  the  care  pf  a  medical  man  off 
and  on  for  the  past  year.  For  the  past  two  years  he  had 
suffered  considerably  from  pain  in  the  upper  part  of  the  body 
coming  on  soon  after  taking  food.  Medical  treatment  had 
never  done  this  any  permanent  good.  He  vomited  occasion- 
ally. In  the  previous  week  he  vomited  blood  once;  the 
amount  was  not  known.  No  history  was  obtainable  pointing 
to  melaena.  On  admission  he  had  a  great  deal  of  pain  on  the 
left  side  of  the  abdomen.  There  was  little  evidence  of  collapse. 
The  pulse  was  88  and  the  respirations  were  quid  and  not 
shallow.  There  were  great  tenderness  of  the  left  side  of  the 
abdomen  and  rigidity;  there  was  little  movement  on  this  side; 
also  dullness  over  the  area  of  the  left  external  oblique  and  left 
iliac  fossa.  Liver  dullness  was  present.  During  tin-  night  he 
vomited  once  and  next  morning  he  was  not  so  well.  The 
breathing  was  a  little  more  hurried  and  -hallow:  the  pulse  was 
100.  The  abdomen  was  a  little  more  distended.  There  were 
tenderness  and  dullness  as  before.  (  hi  the  iith  hi-  general 
condition  improved;  the  pulse  was  90.  The  pain  and  tender- 
ness had  wholl)  disappeared.     There  was  more  distention  of 

the  abdomen.      Movement    \\;i-  fairly  good.      The  (Inline—  on 

the  leii  side  was  now  limited  t<>  the  loin;  this  appeared  on 
rolling  him  on  to  his  righl  side.  On  the  12th  hi-  general  con- 
dition   was   -till    remarkably   ,u<>od.     The    pulse    was   quiet, 


2()i  Duodenal  Ulcer 

under  ioo.  He  was  entirely  free  from  pain  and  took  a  fair 
quantity  of  milk  by  the  mouth.  Abdominal  distension  was 
still  considerable.  The  abdomen  was  very  hard  and  resistant; 
i  here  was  no  tenderness.  Liver  dullness  was  present.  There 
was  no  dullness  on  either  loin.  During  the  afternoon  he 
became  markedly  worse.  He  rapidly  became  extremely 
collapsed,  pale,  cold,  and  sweating.  His  pulse  was  weak  and 
intermittent.  The  abdomen  was  still  more  resistant  and 
distended,  so  that  it  felt  almost  like  a  tightly  blown  football. 
Vomiting  occurred  twice  during  the  afternoon.  Laparotomy 
was  performed  at  6  p.  m.  (median  incision).  A  large  quantity 
of  free,  odourless  gas  was  found  in  the  peritoneum.  There 
was  general  suppurative  peritonitis  The  pelvis  was  full  of 
pus  and  there  was  flaky  lymph  over  the  intestines.  In  the 
anterior  wall  of  the  first  part  of  the  duodenum  an  aperture 
of  the  size  of  a  large  quill  was  found.  This  was  closed  by 
sutures  and  sequestrated  by  stitching  that  surface  of  the 
duodenum  to  the  stomach  wall.  Free  drainage  was  made 
through  both  loins  and  from  the  pelvis.  The  patient  died 
eleven  hours  after,  despite  infusion  (twice)  and  the  usual 
stimulants.  Post-mortem,  an  ulcer  on  the  posterior  wall  of 
the  duodenum  just  beyond  the  pylorus  was  found.  It  was 
an  ulcer  on  the  anterior  wall  which  had  perforated. 

Case  9. — June  30,  1906;  male,  aged  twenty-nine.  Re- 
cently has  noticed  pain  two  or  three  hours  after  a  meal,  and 
a  "sour  fluid"  then  keeps  coming  up  into  his  mouth.  Has 
recently  been  attending  the  out-patient  department  of  the 
Infirmary.  At  12.30  P.  M.,  when  walking  down  the  street, 
felt  a  sudden  excruciatingly  severe  pain  in  the  epigastrium. 
He  fell  on  the  ground  and  could  not  rise.  About  one  hour 
later  he  vomited  "a  pint  of  blood."  .  On  admission  the  abdo- 
men was  distended  and  resistant  everywhere.  There  was 
more  marked  resistance  and  greater  tenderness  on  the  right 
side.  A  diagnosis  of  perforated  duodenal  ulcer  was  made. 
A  perforation  was  found  on  the  anterior  and  upper  part  of 
the  duodenum,  about  Y2  inch  beyond  the  pylorus.  The  per- 
foration was  closed.  Posterior  gastro-enterostomy  was  per- 
formed. The  abdomen  was  mopped  out  (there  was  very  little 
extravasation).     No  drainage.     Patient  recovered. 


Perforation  263 

Case  10. — August  18,  1906;  male,  aged  twenty-eight. 
For  many  months  has  had  vomiting  after  food  if  he  has  hurried 
away  after  a  meal,  not  otherwise.  Fullness  and  pressure  in 
epigastrium.  A  sudden  attack  early  on  Saturday  morning 
(2  a.  M.).  A  perforation  of  a  small  ulcer  in  duodenum  just 
beyond  pylorus;  closure.  On  opening  to  do  posterior  gastro- 
enterostomy it  was  found  that  the  upper  part  of  jejunum  was 
strangulated  in  a  right  duodenal  hernia.  The  obstruction 
had  caused  rupture  of  ulcer.  Posterior  gastroenterostomy. 
Closure  (partial)  of  hernial  opening.  Drainage  and  supra- 
pubic drain.  Patient  recovered.  Was  sent  by  Dr.  Oldfield. 
<  )peration  6.30-  p.  M.,  sixteen  and  one-half  hours  after  per- 
foration. In  this  case  a  very  early  duodenal  ulcer  was  caused 
to  perforate  by  reason  of  the  extreme  distension  of  the  intes- 
tine behind  an  acute  obstruction. 

Case  ii. — July  3d,  1907;  female,  aged  forty-two.  Has 
had  symptoms  of  duodenal  ulcer  for  'many  years.  Under 
treatment  continuously  for  almost  twelve  months.  A  sudden 
acute  attack  of  pain.  On  examination  the  patient  was  gravely 
ill;  the  abdomen  was  hard,  tense,  and  distended.  The  pulse 
was  132  and  the  breathing  shallow  and  panting.  A  perforated 
duodenal  ulcer  just  beyond  pylorus.  Suture;  drained.  Pa- 
tient died.  Was  sent  by  Dr.  Hudson,  Leeds.  Perforation 
twenty-six  and  one-half  hours  before  operation. 


CHAPTER  XI 
THE  PATHOLOGY  OF  CHRONIC  DUODENAL  ULCER 

A  duodenal  ulcer  which  has  been  the  cause  of  pro- 
tracted and  recurrent  symptoms  is  always  visible  from 
the  outside  of  the  intestine,  is  always  palpable,  and 
therefore  is  always  demonstrable.  To  this  statement 
there  are  no  exceptions. 

It  is  remarkable  with  what  constancy  the  same  por- 
tion of  the  duodenum,  identically  the  same,  is  attacked 
by  the  ulcer.  In  at  least  95  per  cent,  of  the  total 
number  of  cases  the  ulcer  lies  within  the  first  portion 
of  the  gut,  that  is,  within  \)/2  inches  of  the  pylorus. 
In  Collin's  series  of  cases,  262  in  number,  the  ulcer  was 
found  in  the  first  portion  in  242,  in  the  second  in  14,  in 
the  third  in  3,  and  in  the  fourth  in  3.  In  Perry  and 
Shaw's  series  of  149  cases  there  were  123  in  which 
the  ulcer  was  in  the  first  part;  16  ulcers  were  in  the 
second  part,  and  2  in  the  third  and  fourth;  in  8  cases 
the  ulcers  were  scattered.  In  Oppenheimer's  81  cases 
the  ulcer  was  in  the  first  part  in  69.  In  my  own  cases, 
and  probably  in  the  records  I  have  just  quoted,  cases 
have  been  described  as  lying  in  the  second  part  when 
they  were  certainly  in  the  first  portion.  It  is  only 
within  the  last  three  or  four  years  that  I  have  realised 
the  remarkable  tendency  of  some  ulcers  to  be  "tucked 
back,"  to  be  adherent  to  the  liver  or  posterior  abdominal 
wall,  and  to  be  there  tethered  in  such  a  manner  as  to 

264 


The  Pathology  of  Chronic  Duodenal  Ulcer    265 

make  it  impossible  to  present  them  in  an  abdominal 
wound.  (In  these  cases  the  pain  after  food  usually 
comes  on  in  three  or  four  hours,  instead  of  in  two,  as 
is  the  rule;  and  before  operation  I  have  frequently 
predicted  with  accuracy  that  this  condition  would  be 
found.)  The  ulcer  in  these  circumstances  may  be  said 
to  be  in  the  second  part  of  the  duodenum,  for  the  bowel 


Fig.  61. — The  Vein  which  Shews  the  Position  of  the  Pylori  -    "Pi 

loric  Vein"). 


in  which  it  lies  seems  to  be  in  close  contact  with  the 
kidneys.  Bui  if  the  position  of  the  pyloric  vein  be 
noted,  il  will  at  once  be  seen  that  the  ulcer  is  within 
'  _.  to  ! ,  of  an  inch  of  the  pylorus.  This  vein  is  a  mosl 
important    landmark';     it    run-   generally   a    little    to    the 

trie  side  of  the  pylorus,  it  is  constant,  and  it-  re< 
nition  during  an  operation  enables  one  to  see  al  .1  glance 


266  Duodenal  Ulcer 

where  the  stomach  ends  and  the  duodenum  begins. 
The  vein  runs  upwards  from  the  greater  curvature 
and  is  thick  and  short.  It  may  oftentimes  be  met  by 
a  -mailer  vein  descending  from  the  lesser  curvature; 
usually  the  two  do  not  meet  in  a  visible  anastomosis. 

The  most  constant  position  for  an  ulcer  is  on  the 
anterior  wall  of  the  duodenum,  midway  between  the 
upper   and    lower   border,    and   almost  exactly   half   an 


Fig.  62. — Duodenal  Ulcer. 
The  usual  position  and  size  of  the  ulcer  are  well  shewn. 

inch  beyond  the  pylorus.  It  must  be  that  this  part  of 
the  duodenum  is  especially  prone  to  attack;  it  may  be 
that  it  is  against  it  that  the  jet  of  chyme  directly  im- 
pinges as  it  is  expelled  through  the  pylorus.  In  its 
early  stages  the  ulcer  is  circular;  the  smallest  ulcer  I 
have  seen  was  a  little  smaller  in  size  than  the  end  of  a  lead- 
pencil.  The  outer  surface  is  white  and  presents  the 
appearance  of  a  cicatrix.  In  some  cases,  however, 
and  especially  if  the  outer  surface  is  wiped  over  with 


The  Pathology'of  Chronic  Duodenal  Ulcer    267 

the  finger  or  with  gauze,  the  ulcer  seems  red  and  vas- 
cular, and  mottled  with  bright,  blood-stained  spots. 
In  older  ulcers  the  base  is  pearly  white,  thick,  and 
puckered  to  the  centre,  which  is  depressed  and  is  densely 
hard.     The  ulcer  then  may  be  picked  up  in  the  fingers, 


Fig.  63.      I  >i  ODENAL  I  'lcer. 

Shewing  adhesions  to  the  gall-bladder.     The  radiating  scar  is  not   infre- 
quently seen. 


and  feels  as  hard  and  dense  as  a  sixpenny  piece,  with  the 
thickness  of  three  <>t  these  coins.  It'  a  finger  be  passed 
hum  behind,  it  will  be  fell  thai  such  an  ulcer  possesses 
.1  crater  into  which  the  tip  of  the  forefinger  may  fit. 
The  crater  seems  always  to  be  smaller  in  size  than  the 


268  Duodenal  Ulcer 

white  external  base;  the  ulcer,  that  is,  would  look 
smaller  from  the  mucous  than  from  the  serous  aspect. 
When  such  an  ulcer  is  excised,  its  inner  surface  generally 
shews  a  clean,  punched-out  appearance;  the  crater 
is  deep  in  proportion  to  its  width,  and  the  sides  are 
thick,  turgid,  and  indurated.  In  some  eases  there 
seem  to  be  steps,  as  it  were,  leading  clown  the  side  of 


Fig.  64. — Duodenal  Ulcer. 

Shewing  the  puckering  up  of  the  scar,  which  leads  to  "pouching"  (drawn 

during  operation  upon  the  case). 

the  ulcer  from  the  lumen  of  the  gut  to  the  base  of  the 
pitted  ulcer.  In  many  of  the  older  records  the  ulcer 
is  said  to  be  "terraced,"  and  in  one  or  two  of  my  own 
specimens  this  appearance  of  ridging  is  very  beautifully 
seen.  In  the  majority  of  the  cases  I  have  observed  the 
ulcer  is  free  from  adhesions,  and  the  bowel  in  which  it 
lies  may  be  brought  well  into  the  abdominal  wound,  or 
outside  of  it,  so  that  any  onlooker  may  easily  inspect  the 


The  Pathology  of  Chronic  Duodenal  Ulcer    269 

parts.  Even  when  the  ulcer  is  quite  small,  one  or  more 
strings  of  adhesions,  or  a  thick  web  of  them,  may  be 
present.  In  its  simplest  form  an  adhesion  may  be  a 
thin  strand  coming  from  the  omentum  to  be  firmly 
implanted  in  the  centre  of  the  ulcer.      It  is  certain  that 


Fig.  65.     I  »i  odenal  Ul<  er. 

Fatal    haematemesis    and    melaena.     The    patienl    had    suffered    from 

1  hyperchlorhydria"   for  seven   years,  on  and  off.     He  was  broughl   into 

the  Leeds  General   fnfirmary  suffering  from  haemorrhage  and  died  in  half 

an  hour.     With  a  lens  the  open  artery  in  the  base  of  the  ulcer  can  be  seen. 


in  this  way  a  perforation  is  prevented  and  a  barrier 
formed  whereby  the  peritoneal  cavity  is  protected.  In 
no  place  is  the  "police"  capacity  of  the  omentum  better 
--hewn   than  here. 

In  the  long-standing  cases  the  size  and  the  thickness 


270  Duodenal  Ulcer 

of  the  ulcer  are  greatly  increased.  The  whole  breadth 
of  the  anterior  wall  of  the  duodenum  may  be  occupied 
by  a  dense,  white,  raised,  fibrous  mass,  which  extends 
even  on  to  the  posterior  surface.  In  one  patient  who 
had  symptoms  on  and  off  for  over  forty  years  the  ulcer 


^ 


J 


i 


Fig.  66. — Chronic  Ulceration  of  Duodenum,  with  Formation  of  a 

Pouch. 
Portions  of  the  duodenum  and  stomach  from  a  case  of  duodenal  ulcer 
fatal  by  haemorrhage.  The  ulcer  is  immediately  contiguous  to  the  pylorus, 
and  is  about  the  size  of  a  two-shilling  piece;  its  edges  are  sharply  cut,  the 
mucous  membranes  being  folded  over  them.  To  the  left  of  the  specimen 
the  ulcer  is  deeply  excavated,  the  base  there  being  formed  by  the  pancreas. 
In  it  is  a  perforated  branch  of  the  pancrcatico-duodenal  artery,  into  which 
a  glass  rod  has  been  introduced  and  from  which  fatal  haemorrhage  occurred. 
Adjacent  to  the  ulcer  and  immediately  contiguous  to  the  pylorus  i-  a 
pouching  of  the  duodenum.     (London  Hosp.  Museum,  Xo.  1152.) 

was  quite  cheloid  in  its  thickness,  density,  and  elevation. 
The  puckering  which  occurs  when  a  mass  of  tissue  con- 
tracts almost  always  seems  to  radiate  towards  the 
centre  of  the  ulcer,  which  is  depressed  to  a  greater  or 


The  Pathology  of  Chronic  Duodenal  Ulcer    271 

less  degree.  The  ulcer  may  then  appear  to  be  star- 
shaped,  the  centre  being  drawn  in  and  dimpled.  The 
appearances  produced  by  this  process  of  puckering  and 
contraction  vary  greatly;  in  some  cases  a  peculiar 
condition  of  ''pouching"  of  the  gut  is  produced.  A 
piece  of  the  duodenal  wall  seems  almost  separated  from 
the  rest,  being  nipped  away  from  it,  as  is  the  bowel  in 
a  Richter's  hernia.  Of  this  I  have  seen  at  least  a 
dozen  good  examples;  the  pouch  so  formed  lies  always 
along  the  lower  border  of  the  gut.  In  some  cases  the 
pouching  may  be  very  considerable,  so  that  a  "diver- 
ticulum" is  formed.  Perry  and  Shaw  give  details  of 
several  "pouched  ulcers"  (pp.  277,  278,  279),  the 
sacculus  being,  in  one,  large  enough  to  contain  a  walnut. 
An  excellent  example  is  seen  in  specimen  11 52  in  the 
London  Hospital  Museum. 

An  interesting  paper  on  "Duodenal  Diverticula"  was 
published  many  years  ago  by  Roth  ("Yirch.  Archiv," 
1872,  lvi,  197).  He  describes  five  cases  illustrating  two 
forms  of  pouch,  the  one  lying  in  the  superior  transverse 
portion  of  the  duodenum,  the  other,  and  more  common, 
in  the  descending  portion,  on  its  posterior  and  inner 
wall,  adjoining  the  pancreas.  The  latter  tonus  are 
now  recognised  to  be  congenital  in  origin;  the  former 
are  acquired  and  are  due  to  the  yielding  of  the  duodenal 
wall  at  or  near  the  site  of  a  chronic  ulcer,  or  to  the 
complete  destruction  of  the  wall  in  the  base  of  an 
ulcer,  and  the  subsequent  deep  erosion  of  the  pancreas. 

L.  S.  Pilcher  ("Annals  of  Surgery,"  [894,  ii.  <>2),  in 
recording  a  case  of  "large  pseudo-diverticulum  of  tin 
duodenum,"  states  that  Morgagni  in  1761  noted  in  the 


272  Duodenal  Ulcer 

body  of  a  man,  fifty-four  years  of  age,  the  existence  of 
a  kind  of  diverticulum  of  the  duodenum,  situated  at 
a  spot  distant  two  digits  below  the  pylorus,  where  a 
loss  of  substance  of  the  mucosa  was  evident,  forming 
an  orifice  capable  of  admitting  a  finger  leading  into  a 
cavity  enclosed  within  the  dilated  outer  coat." 

Pilcher's  case  is  sufficiently  remarkable  to  bear  quota- 
tion in  full: — 

November  18,  1893.  Frederick  B.,  a  boy,  seventeen  years 
of  age,  was  admitted  to  my  service  in  the  Methodist  Episcopal 
Hospital  in  Brooklyn,  with  the  statement  that  his  general 
health  had  been  good  up  to  a  period  about  twelve  weeks  pre- 
viously, when  he  began  to  suffer  from  pain  in  his  abdomen, 
associated  with  tympanites  and  constipation.  Irregular 
chills  and  fever  with  emaciation  followed,  with  diffused  tender- 
ness over  the  whole  abdomen.  Finally,  about  two  weeks  be- 
fore his  admission  to  the  hospital,  a  more  severe  pain  with  a 
manifest  tumour,  which  was  tender  to  touch,  developed  in  the 
right  inguinal  region. 

Upon  admission  he  was  emaciated  and  anaemic,  the  abdomen 
was  flat,  was  somewhat  tender,  and  with  rigid  recti  muscles, 
but  with  no  discernible  tumour.  His  temperature  was  99. 6° 
F.,  pulse  100,  and  respirations  26.  For  some  five  days  his 
temperature  and  pulse  steadily  declined  towards  the  normal 
point.  Then  the  temperature  began  to  display  a  daily  evening 
rise  of  from  two  to  three  degrees,  and  a  dimly  outlined  tumour 
below  the  umbilicus,  projecting  to  the  right  of  the  margin  of 
the  rectus  muscle,  could  be  felt. 

The  abdominal  cavity  was  now  opened  by  a  median  longitu- 
dinal incision  below  the  umbilicus.  Normal-looking  intestines 
and  peritoneum  came  into  view.  Pushing  the  mass  of  small 
intestine  to  the  left,  and  the  ascending  colon  to  the  right,  there 
was  exposed  behind  the  peritoneum,  lying  in  front  of  the  lum- 
bar vertebrae,  and  over  the  great  vessels,  and  projecting  for- 
ward into  the  abdominal  cavity,  a  flattened,  irregularly  heart- 
shaped   tumour,   whose  base   was   lost   under   the   transverse 


The  Pathology  of  Chronic  Duodenal  Ulcer    273 

colon  above,  while  its  apex  overhung  the  brim  of  the  pelvis 
below,  where  it  was  adherent  upon  the  right  side  to  the  last 
portion  of  the  ileum  and  the  adjacent  portion  of  the  caecum. 
A  sense  of  fluctuation  within  it  was  elicited  by  palpation,  and 
while  this  examination  was  in  progress  its  wall  gave  way  on  its 


Hepatic  flexure 
of  duodenum 


Pylorus 


f 


I  [G.  67.     L.  S.  Pilcher's  Case  01   Pseudo-diverticulum  of  the  Duo- 

DENUM. 

One-half  actual  size.  .  1.  Strip  of  mucous  membrane;  B,  B,  inflam- 
matory connective-tissue  wall.  Test-tubes  prut  rude  into  sac  through  the 
openings  into  it  of  the  duodenum  and  the  jejunum  '"Annals  of  Surgerj  "). 


presenting  convexity  sufficiently  to  permi.1  a  few  drops  of  puri- 
form  fluid  to  ooze  out.  The  opening  thus  made  was  enlarged  ; 
an  ounce  or  two  ol  brown,  puriform  fluid  escaped  on  the  sponges; 
the  finger  on  introduction  into  the  cavity  fell  several  small  solid 
masses,  which,  on  removal  with  .1  scoop,  proved  to  be  pieces 
18 


274  Duodenal  Ulcer 

of  parti;  -      1  vegetable  material:  the  cavity  evidently  did 

or  had  recently  communicated  with  the  intestinal  tract  high 
up:  the  exploring  finger,  passed  upwards,  disappeared  under- 
neath the  transverse  colon,  and  did  not  reach  the  upper  limit 
of  the  cavity.  All  its  relations  pointed  to  the  duodenum  as 
the  origin  of  the  abso 

From  the  first  the  general  peritoneal  cavity  was  protected 
l>y  suitably  placed  sponges;  now  the  abscess  cavity  was  irri- 
gated out,  two  drainage-tubes  were  inserted,  and  a  suitable 
packing  of  iodoform  gauze  placed  so  as  to  continue  the  isola- 
tion of  the  abscess  opening  and  the  drainage  track  from  the 
general  peritoneal  cavity. 

The  patient  rallied  well  from  the  operation:  an  abundant 
bilious  discharge  from  the  drainage-tubes  began  at  once  to 
appear,  and  as  soon  as  milk  began  to  be  administered,  this  also 
would  escape  from  the  drainage-tubes  quickly  after  being 
swallowed.  Infection  of  the  general  peritoneum  was  not  pre- 
vented, and  on  the  third  day  the  patient  died  from  the  conse- 
quent peritonitis. 

•  Post-mortem  dissection  shewed  the  tumour  to  be  formed  of. 
a  thick-walled  sac.  its  cavity  holding  about  six  ounces,  broad- 
ening at  its  upper  part,  across  the  posterior  surface  of  which 
part  was  traceable  a  band  of  normal  mucous  membrane,  about 
one  inch  in  width,  which  was  continuous  at  either  lateral  angle 
with  the  proper  intestinal  canal.  At  the  right  upper  horn  the 
descending  portion  of  the  duodenum  opened  directly  into  the 
sac,  pouting  into  it  in  a  manner  resembling  the  termination  of 
the  ileum  at  the  ileo-caecal  junction.  Just  within  the  intact 
duodenum  could  be  demonstrated  the  opening  into  it  of  the 
common  duct. 

The  sac  thus  formed  and  related  was  a  veritable  interrup- 
tion in  the  continuity  of  the  intestinal  canal,  a  large  pocket  or 
diverticulum,  as  shewn  in  the  accompanying  figure  (Fig.  67), 
into  which  all  the  ingesta  transmitted  by  the  .-tomach,  together 
with  the  bile,  was  discharged  by  the  duodenum  on  the  one  side, 
and  from  which  it  had  exit  on  the  other  side  into  the  jejunum. 
Minute  examination  of  the  innermost  layer  of  the  sac  wall 
shewed  it  to  be  composed  purely  of  inflammatory  connective 
le.  except  along  the  limited  portion  mentioned  above,  where 


The  Pathology  of  Chronic  Duodenal  Ulcer    :_: 

the  strip  of  mucous  membrane  was  still  visible.  The  line  of 
demarcation  between  the  mucous  membrane  and  the  in- 
flammatory connective-tissue  lining  was  very  sharp  and  well 
defined. 


In  the  great  majority  of  the  cases  a  healthy  margin 
of  the  bowel  lies  between  the  ulcer  and  the  pylorus, 
but  the  lesion  may  extend  up  to.  or  may  even  trans- 
gress, the  pylorus.  It  is  interesting  to  know  that  when 
it  does  so.  the  gastric  margin  of  this  ulcer  may  be.  as 
Dr.  W.  J.  Mayo  has  shewn,  the  starting-point  of  a 
carcinomatous  growth.  The  occurrence  of  a  malignant 
change  in  a  duodenal  ulcer  is  extremely  rare:  in  onlv 
two  cases  have  I  seen  it.  The  change  from  a  simple 
to  a  malignant  form  in  gastric  ulcer  is.  of  course,  not 
very  infrequent:  it  would  appear  that  approximatelv 
two  cases  in  three  of  cancer  of  the  stomach  have  their 
origin  in  an  open  chronic  ulcer  or  in  the  scar  of  a  partiallv 
or  completely  healed  one.  Ulcus  carcinomatosum  in 
the  duodenum  must  be  excessively  rare. 

The  recurrence  of  the  "attacks"  in  duodenal  ulcer 
may  be  due  to  the  healing  and  the  breaking  down,  often 
repeated,  of  a  solitary  ulcer:  or  to  the  development  of 
new  ulcers.  It  is  certain  that  the  former  is  of  far  greater 
frequency  than  the  latter,  for  it  is  not  in  more  than  [0 
ent.  of  the  -  hat  more  ulcers  than  out- 
ran be  seen.  In  thi>  statement  there  is.  however,  a 
source  of  fallacy;  for  the  large  ulcer  which  i>  not  seldom 
found  may  have  been  due  to  the  merging  of  one  small 
ulcer  with  another,  and  these  into  a  third,  and  >o  on. 
That  this  ile  seems  clear  from   the  close  pr 

imity   that   the  -mall    -  healed   ul>  etimes 


276 


Duodenal  Ulcer 


bear  to  one  another.  In  this  process  of  healing  and  of 
breaking  down  a  great  mass  of  new  fibrous  tissue  may 
be  formed;  in  one  case  a  tumour,  noted  at  the  time  to 
be  "of  the  size  of  a  lemon,"  was  found  in  the  first  part 
of  the  duodenum  around  an  ulcer  whose  crater  was 
a]  (proximately  the  size  of  a  florin.  The  cicatricial  tissue 
in  the  base,  and  on  all  sides  surrounding  the  ulcer, 
undergoes,    as    it   does   everywhere,    a    process    of   con- 


Fig.  68. — Hour-glass  Stomach  and  Duodenum. 


traction;  and  contraction  occurring  in  the  wall  of  a 
tube  of  small  lumen  results  in  a  formidable  narrowing 
of  its  calibre.  A  stenosis  of  the  duodenum  is  formed 
in  this  way.  The  stricture  may  be  as  thin  as  whipcord, 
and  almost  circular,  narrowing  the  bowel  precisely  as 
if  a  string  had  been  tied  around  it,  or  the  stricture  may 
be  long  and  tortuous  and  greatly  indurated.  If  the 
former,  a  condition  of  "hour-glass  duodenum"  may  be 


The  Pathology  of  Chronic  Duodenal  Ulcer    277 

found.  Of  this  I  have  seen  several  examples.  Kenneth 
Mackenzie  ("Journ.  Amer.  Med.  Assoc,"  1906,  i,  341 
gives  notes  of  cases  occurring  in  his  own  practice  in 
which  this  condition  was  well  seen.  Narrowing  of  the 
lumen  may  be  caused  both  by  the  massive  deposit  of 
lymph  in  and  around  the  ulcer,  and  by  the  firm  contrac- 
tion of  the  scar  of  an  ulcer  which  has  completely  healed. 
In  one  of  my  cases  of  hour-glass  stomach  a  double 
stenosis  was  found ;  it  was  due  to  the  tight  contractions 
caused  by  two  ulcers,  one  immediately  beyond  the 
pylorus,  and  one  an  inch  away.  The  following  are  the 
notes  of  the  case: 

Dual  stenosis  of  the  duodenum,  associated  with  hour- 
glass stomach:  January  20,  1903;  female,  aged  thirty-one. 
Nine  and  a  half  years  ago  vomited  a  "great  deal"  of  blood. 
Dr.  James  Mackenzie  then  diagnosed  ulceration  of  the  stomach. 
Since  then  has  always  been  ailing,  especially  after  a  moderate 
meal.  Five  years  ago  was  very  ill:  acute  abdominal  pain; 
severe  vomiting  and  huematemesis.  Was  in  Manchester 
Royal  Infirmary  with  "ulcer  of  the  stomach."  One  and  a 
half  years  ago  had  hsematemesis.  For  several  years  has  had 
no  solid  food  and  has  never  had  an  ordinary  meal.  Has 
lived  on  milk,  custards,  porridge.  On  examination  an  hour- 
glass stomach  was  diagnosed.  Wolfler's  two  signs;  para- 
doxical dilatation;  increase  in  subcostal  tympany;  gurgling 
sound  a1  lefl  cud  of  stomach,  all  well  marked.  At  the  opera- 
tion an  hour-glass  stomach  and  an  hour-glass  duodenum  were 
found.  There  were  two  large  stomach  pouches,  united  by  a 
narrow  i>thmus,  at  the  lesser  curvature.  Tighl  constriction 
at  the  pylorus;  the  first  portion  of  the  duodenum  was  dilated 
to  form  .1  s.ie  the  size  of  a  lemon;  beyond  this  another  con- 
striction. The  pyloric  pouch  of  the  stomach  was  more 
densely  scarred  than  any  stomach  I  have  seen;  its  texture 
was  almost  wholly  fibrous.  <  hi  its  posterior  surface  also 
many   star-    were    seen.     Gastro-enterostomy   and    posterior 


2~x  Duodenal  Ulcer 

gastro-enterostomy  to  the  pyloric  pouch.  The  patient  re- 
covered. The  patient  was  sent  by  Dr.  Mackenzie,  Burnley. 
Within  three  weeks  of  the  operation  she  ate  solid  food  heartily, 
and  had  taken  all  the  vegetables  in  season.  In  June,  1905, 
quite  well,  taking  ordinary  diet.     Was  well  in  1908. 

A  similar  case  is  also  recorded  l>y  W.  J.  Mayo  ("  Journ. 
•Amer.  Med.  Assoc,"  1908,  ii,  556). 

In  a  certain  proportion  of  cases  (between  10  and  20 
per  cent.)  the  ulcers  are  multiple.     There  are  sometimes 


Fig.   69. — Double   Stenosis   in   the   Duodenum    ("Hour-glass    Duo- 
denum")  (after  W.  J.  Mayo). 


seen  on  the  anterior  surface  of  the  duodenum  two,  three, 
four,  or  more  old  white  scars  with  an  ulcer  which  is 
clearly  of  more  recent  origin,  and  in  a  more  active  con- 
dition. The  base  of  this  last  ulcer  may  be  thick  and 
tumid,  the  peritoneum  over  it  rough,  red,  and  shaggy, 
and  a  new  adhesion  from  the  omentum  may  be  drawn 
up  to  strengthen  its  base.  Old  ulcers  and  new  ones  are 
found  side  by  side.  When  two  ulcers  are  present,  they 
are  nearly  always  close  together,   almost   touching;    or 


The  Pathology  of  Chronic  Duodenal  Ulcer   279 

the  one  lies  on  the  posterior  wall  of  the  bowel  immedi- 
ately opposite  to  the  anterior  ulcer.  The  two  ulcers 
seem  then  to  have  been  in  exact  apposition  when  the 
gut  was  empty;  I  suggested  the  term  "kissing  ulcers," 
or  contact  ulcers,  for  them.  The  impression  is  confi- 
dently  derived    from    their   inspection    that    the   one   is 


Fig.  70. 

A,  Perforating  ulcer  on  anterior  surface  of  duodenum;  B,  "kissing 
ulcer"  on  posterior  surface;  C,  pyloric  ring;  D,  D,  cut  edge  of  lesser  curvat- 
ure of  stomach.  Note  the  position  of  the  ulcers  immediately  outside 
the  pylorus. 

The  specimen  was  removed  from  a  woman  aged  thirty,  who  died  about 
two  hours  after  admission  to  the  Royal  Victoria  Hospital,  Belfast  (May, 
1909J.  No  operation  was  undertaken.  (From  a  photograph  kindly 
given  to  me  by  Dr.  A.  B.  Mitchell,  Belfast.) 

infected  from  the  other.  When  more  ulcers  than  one 
are  present,  they  .ire  all  usually  grouped  together  in  the 
first  pari  of  the  duodenum.  I  have  once  -ecu  nine 
definite  -ear-  within  the  -pace  of  I  '  „.  inches;  and  main 
time-    I    have   found    three,    four,   or   five   ulcers.     The 


28o 


Duodenal  Ulcer 


upper  and  the  lower  borders  bear  ulcers  occasionally, 
though  when  a  scar  is  present  in  either  place,  other  scars 
are  generally  found  on  the  anterior  surface.  A  solitary 
ulcer  on  the  posterior  surface  is  rare;  I  have  only  met 
with  three,  in  all,  when  we  were  quite  certain  that  no 
other  part  of  the  bowel  was  involved.     Inspection  of 


Fig.  71. — Circular  Ulcer  of  Duodenum. 

Perforation  into  a  localised  abscess  (Meunier). 


the  posterior  surface  can  most  easily  be  carried  out 
through  the  opening  made  in  the  transverse  mesocolon 
for  posterior  gastro-enterostomy.  The  enormous  pre- 
ponderance of  anterior  over  posterior  ulcers  in  point 
of  frequency  cannot  possibly  be  due  to  caprice.  There 
must   be   some   substantial    reason   for  it,    but  of  such 


The  Pathology  of  Chronic  Duodenal  Ulcer    281 

reason  we  have  no  present  knowledge.  When  several 
ulcers  are  present,  there  is  usually  one  which  seems  to 
have  more  active  processes  engaged  in  it;  but  there  are 
times  when  two  or  even  three  ulcers  would  seem,  from 
their  appearances,  to  be  of  equal  age  and  activity.  Two 
such  ulcers  may  perforate  at  the  same  moment  (Biggs: 
"New  York  Med.  Journ.,"  1890,  i,  77).  One  case  is 
recorded  in  which  the  ulcer  was  circular  and  had  divided 
the  duodenum  completely  across: 

Annular  ulcer  of  the  duodenum  (Henri  Meunier:  "Bull. 
Soc.  Anat.,"  1893,  i,  488):  Henri  L.,  journalist,  age  sixty-one, 
admitted  under  Dr.  Millard  for  severe  dyspeptic  troubles. 
Illness  commenced  three  months  ago  with  epigastric  pain, 
loss  of  appetite,  and  vomiting.  On  admission,  June  28th, 
both  the  general  and  local  conditions  were  strongly  suggestive 
of  cancer.  Face  cachectic,  marked  wasting  of  the  body, 
abdomen  distended  by  a  dilated  stomach.  In  the  pyloric 
region  was  a  resistant  swelling,  somewhat  tender,  obstinate 
constipation,  frequent  vomiting,  the  vomit  containing  food 
material  taken  several  days  previously.  Lavage  of  stomach 
gave  some  relief.  The  cachexia,  however,  gradually  became 
worse,  and  death  occurred  on  July  8th. 

Post-mortem:  Acute  general  peritonitis.  In  the  pyloric 
region  the  following  remarkable  conditions  were  presenl  : 
A  cavity  was  present  under  the  liver,  bounded  above  by  the 
inferior  surface  of  the  liver,  in  front  by  the  gall-bladder, 
below  by  the  thickened  transverse  mesocolon,  behind  by  a 
thickened  peritoneal  pseudo-membrane.  All  the  walls  of  the 
cavity  were  united  together  by  fibrous  adhesions,  which  com- 
pletely -luii  it  off  from  the  general  peritoneal  cavity.  The 
contents  of  this  cavity  consisted  of  a  fluid  similar  to  'Ik-  fluid 
found  in  the  stomach  and  containing  food  particles.  On 
remo\  ing  this  the  duodenum  was  found  completely  cul  across. 
The  division  was  situated  aboul  3  cm.  from  the  pylorus,  and 
the  ends  were  a-  clean  cut  as  if  the  section  had  been  made 
with   scissors.     There  was  no  sign  of  cancerous  induration. 


282  Duodenal  Ulcer 

The   gall-bladder   had    thickened   walls    and    contained    bile, 
but  no  stones. 

The  cicatricial  contraction  of  the  ulcer  may  involve 
other  structures  and  give  rise  to  various  symptoms. 
It  is  well  known  that  when  the  ulcer  lies  near  or  around 
the  ampulla  of  Vater,  a  stenosis  of  the  diverticulum 
may  result,  and  so  the  common  bile-ducts  and  the  canal 
of  Wirsung  may  be  involved.  Jaundice  and  grave 
inanition  may  consequently  ensue,  and  a  suspicion  of 
carcinoma  of  the  pancreas  may  be  bred.  The  follow- 
ing cases  may  be  quoted  (see  also  Krauss:  "  Das  pcrforir- 
ende  Geschwiir  im  Duodenum,"  Berlin,  1865): 

I.  Old  duodenal  ulcer  affecting  region  of  diverticulum; 
cicatrisation;  obstruction  of  bile-duct;  distension  of  gall- 
bladder; jaundice;  obstruction  of  pancreatic  duct,  atrophy 
of  pancreas  (Krauss,  Case  13,  page  21):  Man  of  thirty-eight, 
well  built,  always  healthy  until  March,  1862,  when  he  began  to 
suffer  from  severe  pain  in  the  right  costal  margin.  After 
eight  days  jaundice  set  in,  which  gradually  increased  in 
intensity;  admitted  to  hospital  in  June;  intense  jaundice, 
with  itching  and  yellow  vision;  abdomen  somewhat  distended ; 
liver  extended  to  the  umbilicus;  in  the  anterior  border  could 
be  felt  a  large,  rounded,  fluctuating  swelling — the  gall-bladder. 
Death  took  place  in  November.  On  section  the  bile-passages 
were  all  dilated;  gall-bladder  greatly  distended  and  filled  with 
a  light  yellowish,  watery  fluid;  liver  enlarged;  at  one  part  of 
the  gall-bladder  the  wall  was  softened  and  nearly  perforated. 
The  hepatic  duct  and  common  bile-duct  were  both  dilated, 
the  opening  of  the  latter  being  extremely  narrow,  situated 
in  a  cicatrised  duodenal  ulcer.  Numerous  adhesions  were 
present  at  this  spot  between  the  duodenum,  head  of  the 
pancreas,  and  all  the  surrounding  tissues.  The  scar  of  the 
ulcer  was  situated  over  the  place  where  the  pancreatic  duct 
enters  the  duodenum.  This  duct  was  greatly  dilated  and  was 
filled  with  light  coloured  fluid.     Its  ostium  was  closed. 


The  Pathology  of  Chronic  Duodenal  Ulcer    283 

II.  Duodenal  ulcer  in  region  of  diverticulum  of  Vater; 
closure  of  common  bile-duct;  distension  of  gall-bladder; 
jaundice;  rupture  of  gall-bladder;  pancreas  atrophic  (Herz- 
felder:  "Wiener  Zeitschrift,"  1856,  xii,  127  and  146,  and 
"Schmidt's  Jahrbticher,"  92,  p.  50) :  Man  of  forty-six,  suffered 
from  cramp  in  the  stomach  for  five  years;  sour  eructations, 
two  years.  Appetite  good,  but  severe  pain  at  night  in  stomach 
region,  relieved  by  vomiting;  stomach  dilated;  sarcinse  and 
food-remains  in  vomit;  cessation  of  symptoms  for  some  time, 
then  fever,  jaundice,  which  rapidly  increased  in  intensity. 
Liver  and  gall-bladder  increased  in  size — swelling  disappeared 
before  death.  On  section  an  ulcer  was  found  on  the  posterior 
wall  of  the  duodenum  as  large  as  a  dollar;  opening  of  common 
duct  closed  by  cicatrix;  stomach  dilated  and  hypertrophied; 
gall-bladder  ruptured. 

III.  Duodenal  ulcer  in  the  neighbourhood  of  the  divertic- 
ulum of  Vater;  stenosis  of  biliary  and  pancreatic  ducts: 
suppurative  inflammation  of  both  ducts;  perforation  of  gall- 
bladder (Forster:  "Wurzburger  medizinische  Zeitschrift," 
1861,  ii,  158):  Man,  seventy-six  years  of  age,  had  symptoms 
of  biliary  retention  for  a  year.  Increased  jaundice,  frequent 
complaints  of  pain  in  liver  region,  rapid  wasting,  and  death 
from  peritonitis  due  to  ruptured  gall-bladder.  On  section, 
fibrinous  suppurative  peritonitis.  A  scar  was  found  at  the 
entrance  of  the  ductus  choledochus  and  pancreaticus  in  the 
duodenum.  The  two  ducts  opened  near  one  another;  numer- 
ous small  polypoid  growths  found  in  this  position.  Although 
each  admitted  an  ordinary  sound,  there  apparently  was  sten- 
osis of  both  passages.  The  pancreatic  duct  was  dilated  over 
nearly  its  whole  extent  and  contained  pus.  The  common 
duct  was  of  the  diameter  of  the  small  intestine  and  tilled  with 
sero-purulent  material.  The  dilation  extended  back  to  the 
small  bile-passages. 

Four  similar  cases  are  recorded  by  Perry  and  Shaw 
(pp.  273,  274);  one  case  by  Budd  ("Diseases  of  the 
Liver,"  [857,  page  204);  one  by  Z<>ia  ("Gaz.  Med.  di 
Torino,"  1899,  i,  [34) ;  one  by  Mackenzie  ("St.  fhomas's 


284  Duodenal  Ulcer 

Hosp.  Reports,"  1890,  xx,  341);  and  one  by  Fenwick 
("Ulcer  of  the  Stomach  and  Duodenum,"  London, 
1900,  Case  44,  page  296). 

The  common  duct  may  also  be  involved  if  the  ulcer 
lies  in  the  first  or  at  the  junction  of  the  first  and  second 
portions,  on  the  upper  and  posterior  walls.  The  com- 
mon duct  as  it  passes  behind  the  duodenum  may  then 
be  gripped  firmly  by  the  scar  and  a  complete  closure  of 
its  lumen  result.  The  following  case,  which  was  under 
my  care,  is  an  exemplary  instance  of  this: 

Obstruction  of  common  bile-duct  by  duodenal  ulcer; 
chronic  pancreatitis;  cholecysto-colostomy:  J.  D.,  male,  aged 
fifty.  Complains  of  jaundice  of  great  intensity.  Until 
nearly  the  end  of  July  was  quite  well.  At  that  time  began  to 
suffer  from  flatulence  and  distension  after  food.  Pain  never 
acute  or  colicky,  no  vomiting.  Occasionally  periods  of  relief 
for  a  few  days,  but  the  attacks  continued  to  return  until  six 
weeks  ago,  when  he  became  jaundiced.  Since  then  pain  has 
been  absent,  but  jaundice  has  gradually  deepened.  There 
has  been  no  pyrexia,  no  rigors,  nor  does  he  think  the  jaundice 
has  lessened  in  intensity.  Has  lost  2  stone  in  weight.  On 
examination  of  abdomen  the  liver  is  felt  to  be  enlarged  and  is 
smooth  and  regular.  The  gall-bladder  can  be  indistinctly  felt. 
It  does  not  project  far  beyond  the  liver  border.  Just  above 
the  umbilicus  an  indistinct  mass  was  felt  on  one  occasion  which 
suggested  an  enlarged  pancreas. 

Pathological  report  of  urine  and  fa?ces  (by  Dr.  Helen  G. 
Stewart) :  A  well-marked  pancreatic  reaction  in  the  urine 
points  to  some  degree  of  chronic  pancreatitis,  which  is  con- 
firmed by  examination  of  faeces.  There  is  a  high  percentage  of 
total  fats,  of  which  nearly  half  are  combined  fatty  acids, 
indicating  that  although  the  pancreas  is  affected,  occlusion 
of  the  pancreatic  duct  is  not  complete,  and  the  obstruction  to 
the  common  bile-duct  must  be  above  its  junction  with  the 
pancreatic.  That  obstruction  of  the  common  duct  is  almost 
complete  is  shewn  by  the  presence  of  only  a  trace  of  stercobilin 


The  Pathology  of  Chronic  Duodenal  Ulcer    285 

in  the  faxes,  but  the  absence  of  undigested  matter  in  the  feces 
also  supports  the  conclusion  that  the  primary  site  of  the  disease 
is  in  the  common  bile-duct,  and  not  in  the  pancreas. 

Diagnosis:  Obstruction  of  common  bile-duct  at  a  point 
above  the  bile-papilla  from  some  other  cause  than  carcinoma 
of  the  pancreas. 

Operation,  October  13,  1908:  The  liver  "was  enlarged  and 
the  gall-bladder  much  distended,  with  thickened  walls,  al- 
though it  did  not  project  beyond  the  lesser  margin  for  more 
than  a  short  distance.  Common  duct  dilated  as  far  as  upper 
margin  of  duodenum.  There  was  an  indurated  scar  in  the 
duodenal  wall  which  involved  the  duct  and  compressed  it  to 
complete  obstruction.  The  scar  was  adherent  to  and  seemed 
to  involve  the  adjacent  part  (only)  of  the  head  of  the  pancreas. 
No  tumour  of  the  head  of  the  pancreas.  No  calculi  palpable. 
Gall-bladder  aspirated  and  found  to  contain  clear  mucus 
only.  It  was  decided  to  perform  a  cholecyst-enterostomy. 
The  duodenum  could  not  be  brought  up  to  the  gall-bladder 
without  dangerous  tension,  and  so  the  anastomosis  was  made 
between  the  gall-bladder  and  transverse  colon.  Wound 
closed. 

The  patient  was  sent  by  Dr.  Dunderdale,  Blackpool,  who 
reports  in  March,  1909:  "He  is  somewhat  sallow,  his  appetite 
is  good,  and  he  has  gained  2  stone  since  the  operation.  Be- 
tween December  28,  1908,  and  January  5,  1909,  had  three 
attacks  of  colicky  pain  over  the  gall-bladder  region,  followed 
by  elevation  of  temperature  and  jaundice  lasting  three  or 
tour  days.  He  now  appears  to  be  quite  free  from  all  his 
former  inconvenience.  The  urine  contains  no  bile.  The 
pancreatic  reaction  has  almost  disappeared." 

In  <  )< -tober,  1909,  I  saw  this  patient;  he  was  then  quite  well, 
and  had  gained  \}/2  stone  since  March.  The  jaundice  had 
entirely  disappeared. 

A   very   few   cases   similar  to   this  are  found   in   the 

literal  ure.      Case   [9  in  Trier's  work  is  the  following: 

Duodenal  ulcer  compressing  the  common  bile-duel  and  the 
portal  vein:    M.,  forty-one  years.     Three  years  previous  to 


286  Duodenal  Ulcer 

his  fatal  illness  he  had  an  attack  of  epigastric  pain  and  vomit- 
ing, lasting  thirteen  weeks,  on  and  off.  In  November  he 
had  pain  in  the  back  and  "haemorrhoids."  On  the  17th  of 
the  following  January  vomited  I  pint  of  dark  blood  whilst  at 
work;  this  haemorrhage  recurred  twice  that  day,  and  he 
nearly  died.  Melsena  was  present.  Five  days  after  vomited 
again  4  or  5  ounces  of  blood.  Blood  was  passed  by  the  bowels 
continuously  and  he  died  from  haemorrhage  on  January  26th. 
Post-mortem:  Stomach  contained  some  pounds  of  firmly 
coagulated  blood.  Varicosities  of  lower  oesophageal  veins 
seen.  No  ulceration.  In  duodenum,  1^4  inches  from  pylorus, 
was  a  flat  ulcer  size  of  Yi  Silbergroschen.  An  opening  the  size 
of  a  pin's  head  ran  from  it  towards  middle  line.  Around 
this  tract  was  a  mass  of  inflammatory  tissue  which  pressed 
up  and  caused  narrowing  of  the  common  bile-duct  and  oc- 
clusion of  the  portal  vein,  which  was  filled  by  a  thrombus 
reaching  up  to  the  liver.  There  was  an  inflammatory  mass, 
size  of  a  walnut,  lying  behind  the  stomach.  Intestines  con- 
tained much  blood. 

The  following  case  is  recorded  by  Swensson  (C.  Wallis, 
"Hygeia,"  Stockholm,  1888,  i,  342): 

Case  of  duodenal  ulcer  with  obliteration  of  the  ductus 
choledochus,  cystic  and  hepatic  ducts,  and  duct  of  Wirsung: 
A  man  of  forty-three  had  suffered  for  ten  months  from  jaun- 
dice, wasting,  and  epistaxis;  the  gall-bladder  was  palpable. 
Operation  performed  without  anaesthesia.  First  jejunal  loop 
brought  out  through  the  wound,  gall-bladder  emptied  by 
puncture  and  sutured  to  the  jejunum.  Death  three  days 
after  operation. 

Post-mortem:  An  ulcer  was  present  in  the  duodenum, 
commencing  in  its  superior  portion  and  extending  into  the 
vertical  portion.  Edges  and  base  of  ulcer  hard  and  callous; 
the  induration  extended  to  the  porta  hepatis.  Ductus  chole- 
dochus could  not  be  found.  Both  the  cystic  and  hepatic 
ducts  were  extremely  dilated  and  each  terminated  in  a  cul-de- 
sac.  Canal  of  Wirsung  also  dilated  and  terminated  in  a  cul- 
de-sac  on  the  indurated  connective  tissue  in  and  behind  the 
ulceration. 


The  Pathology  of  Chronic  Duodenal  Ulcer    287 

A  case  of  the  same  type  is  this: 

Duodenal  ulcer  causing  obstruction  of  common  duct 
(Marchiava,  E.:  "Bericht  iiber  der  Verhandl.  de  Ital.  Pathol. 
Gesellschaft,  Rom.,"  26-29,  April,  1905;  "Centralbl.  f.  allg. 
Pathol.,"  1906,  xvii,  325) :  Case  of  duodenal  ulcer  is  described 
which,  by  extension  of  the  inflammatory  process,  produced  a 
periduodenitis  as  a  result  of  which  compression  of  the  ductus 
choledochus  took  place.  The  ulcer  later  invaded  a  portion 
of  the  duct,  producing  a  complete  division  of  the  same  into  a 
lower  portion  with  two  openings  (one  leading  normally  into 
the  papilla,  the  other  into  the  ulcer)  and  an  upper  portion 
passing  into  the  ulcer  from  which  the  bile  flowed  out.  Finally, 
infection  of  the  bile-ducts  with  formation  of  abscess  in  the 
liver  took  place.  Rupture  of  one  of  these  abscesses  and 
peritonitis  ensued. 

A  -imilar  case  is  recorded  by  J.  H.  Morgan  ("Trans. 
Path.  Soc,"  1876,  xxvii,  176),  who  shewed  at  the  Patho- 
logical Society  a  specimen  in  which  there  was  an  enor- 
mous dilatation  of  the  bile-ducts  from  a  stricture  of  the 
ductus  communis  choledochus,  due  to  the  contraction 
in  the  base  of  a  duodenal  ulcer. 

"The  liver  exhibited  shewed  a  condition  of  extreme  dis- 
tension and  dilatation  of  the  gall-bladder,  its  ducts,  and  the 
bile-ducts  in  the  substance  of  the  liver.  It  was  removed 
from  the  body  of  a  patient  who  came  to  St.  George's  Hos- 
pital as  an  in-patient  on  April  21,  1875,  under  Dr.  Dickinson, 
to  whom  I  am  indebted  for  the  following  notes;  lli-  age 
was  fifty-two,  and  he  was  by  occupation  a  plumber.  He 
came  of  healthy  parents,  and  had  enjoyed  good  health  till 

four  month'-  before  admission,  when  he  had  -uttered  from  an 
abscess  in  the  hand  following  a  prick  when  at  work.  This 
was  followed  by  cold,  shivering,  and  diarrhoea,  and  .1  day  or 
two  after  thi>  jaundice  had  commenced.  He  appeared  to 
be  well  nourished  when  admitted;  his  ^kin  was  a  bright 
yellow  colour,  the  hides  and  conjunctivae  deeply  bile-stained. 


288  Duodenal  Ulcer 

He  complained  of  constant  headache  and  occasional  pain  at  a 
spot  to  the  right  side  of  the  ensiform  cartilage.  This  pain 
was  increased  by  pressure  and  aggravated  by  coughing. 
The  right  rectus  abdominis  muscle  was  very  tense.  The 
tongue  was  coated  and  the  bowels  loose.  The  faeces  were 
light  and  stone-coloured,  and  the  urine  contained  large  quan- 
tities of  bile.  No  enlargement  of  the  liver  could  be  detected 
at  this  time.  In  spite  of  all  treatment  his  condition  continued 
much  the  same  for  a  month,  when  he  began  to  suffer  from 
intolerable  itching,  preventing  sleep,  and  causing  him  to 
scratch  his  skin  till  it  bled.  No  blood  was  at  any  time  ob- 
served in  the  motions  and  no  gall-stones  were  passed.  On 
July  2d  the  liver  was  found  to  be  much  enlarged,  both  lobes 
projecting  forwards,  and  giving  rise  to  two  tumours,  slightly 
elevated  above  the  surrounding  surface  of  the  body.  The 
patient  gradually  got  worse,  and  died  on  July  9th. 

"At  post-mortem  examination,  made  by  myself  fourteen 
hours  after  death,  the  skin  and  all  the  organs  of  the  body  were 
found  to  be  deeply  stained  with  bile.  There  was  extensive 
fatty  degeneration  of  the  muscular  tissue  of  the  heart.  The 
liver  was  greatly  enlarged  and  distended;  its  surface  smooth 
and  presenting  several  slight  elevations,  whose  thin  and  trans- 
parent walls  and  fluid  contents  had  all  the  appearance,  at 
first  sight,  of  cysts.  These  were  found  especially  on  the  under 
surface  of  the  left  lobe,  their  sizes  varying  from  an  inch  and  a 
quarter  to  a  quarter  of  an  inch  in  circumference.  The  gall- 
bladder was  much  distended.  It  measured  from  5  to  6  inches, 
and  projected  some  distance  below  the  edge  of  the  liver;  it 
contained  dark-green  inspissated  bile  mixed  with  mucus  and 
epithelium.  A  stricture  of  the  common  bile  duct  existed 
just  below  the  point  of  its  formation  by  the  cystic  and  hepatic 
ducts.  There  was  but  little  thickening  of  the  walls  of  the 
duct,  and  below  the  point  of  stricture  it  was  patulous  and  of 
the  normal  colour  and  calibre;  above  it  was  dilated  to  the 
size  of  a  large  finger,  and  stained  green  with  bile.  On  the  outer 
side  of  the  duct  the  duodenum  was  found  to  be  bound  down 
to  it  by  adherent  bands  of  lymph,  and  on  tearing  them  apart 
a  perforating  ulcer  was  found  to  exist  at  this  spot  in  the  walls 
of  the  gut,  which  was  only  prevented  from  extravasating  its 


The  Pathology  of  Chronic  Duodenal  Ulcer    289 

contents  by  the  adhesion.  The  contraction  of  this  lymph 
round  the  duct  had  caused  its  constriction.  Another  ulcer 
not  so  far  advanced  was  seen  to  exist  close  to  this  one.  The 
result  of  this  constriction  was  an  obstruction  to  the  onflow 
of  the  secretion,  and  hence  a  dilatation  of  all  the  ducts.  This 
had  caused  the  distension  of  the  gall-bladder  and  its  duct, 
and  also  those  of  the  liver,  which  it  had  distended  to  such  an 
extent  as  to  cause  their  extremities  to  project  on  the  surface 
as  the  cysts  above  described.  The  circumference  of  the  duct 
of  the  left  lobe  measured  over  an  inch.  These  cysts  collapsed 
on  pressing  out  their  contents,  which  consisted  of  viscid, 
slightly  green  mucus  and  epithelium." 

The  following  case  is  recorded  by  Horace  Packard 
("Boston  Medical  and  Surg.  Journ.,','   1908,  ii,   106J: 

In  February,  1907,  I  was  summoned,  in  consultation  by  Dr. 
0.  R.  Chadwell,  over  a  case  of  very  profound  icterus.  The 
patient  was  a  man  of  medium  height,  spare  in  his  build,  seden- 
tary in  his  habits,  engaged  in  intellectual  pursuits,  and  with 
very  pronounced  ideas  on  food  and  nutrition — a  vegetarian. 
His  frugality  had  been  carried  to  such  an  extent  that  he,  at 
limes  for  considerable  periods,  partook  of  nothing  in  the  way 
"I  nutriment  but  nuts  and  raisins.  His  first  attack  of  jaundice 
occurred  about  three  years  prior  to  my  relation  with  his  case. 
Under  treatment  this  had  cleared  up  and  in  the  intervening 
time  up  to  the  present  illness  he  had  pursued  his  usual  routine 
of  life. 

One  month  ago  he  had  again  become  jaundiced  coincident 
with  an  attack  of  grippe;  the  stools  became  clayey  and  the 
urine  very  dark.  He  had  pain  in  the  epigastrium  and  right 
hypochondrium,  chills,  and  one  attack  of  nausea.  No  sub- 
scapular pain.  The  stools  later  had  become  very  black  and 
were  still  SO. 

Physical  examination  disclosed  general  icterus  of  the  highest 
degree  oi  intensity;  emaciation;  heart  and  hum-  normal; 
abdomen  tl.it  and  of  normal  percussion  note  except  in  the 
righl  hypochondrium,  when-  an  elongated  oval  smooth  tumour 
could  be  easily  detected  on  palpation,  extending  from  the  re- 


290 


Duodenal  Ulcer 


gion  of  the  eighth  costal  cartilage  to  below  the  level  of  the 
umbilicus.  The  tumour  was  evidently  the  gall-bladder, 
enormously  distended,  such  as  is  not  infrequently  met  as  a 
result  of  plugging  of  the  cystic  duct  by  a  gall-stone.  So  pro- 
found icterus,  however,  could  hardly  be  explained  by  such  a 
physical  condition,  therefore  it  was  assumed  that  there  must 
be  some  pathological  condition  in  the  common  duct  which  had 


Fig.  72. 
Shewing  ulcer  at  ampulla  of  Vater;    and  the  divided  common  duct  anasto- 
mosed with  the  duodenum. 


brought  about  complete  obstruction  to  the  overflow  of  bile. 
The  most  plausible  theory  was  plugging  by  a  biliary  calculus. 
At  the  same  time  there  was  the  disquieting  fact  of  intensely 
black  stools,  which  could  be  accounted  for  in  no  other  way  than 
by  the  escape  of  blood  into  the  intestinal  tract.  Accepting 
this  theory  the  question  then  arose:  What  causes  such  escape 
of  blood,  and  has  the  well-known  haemophiliac  tendency  of 
the  icteric  state  anything  to  do  with  it?     There  had  been  no 


The  Pathology  of  Chronic  Duodenal  Ulcer    291 

symptoms  indicative  of  ulcer  of  the  stomach.  There  was  no 
history  of  black  stools  prior  to  the  attacks  of  jaundice,  and, 
as  far  as  I  could  learn,  no  thought  has  arisen  in  the  minds  of 
any  of  his  previous  medical  advisers  of  ulcer  of  the  duodenum. 
As  the  case  is  viewed  now  in  the  light  of  subsequent  develop- 
ments it  appears  that  the  black  stools  were  the  key  to  the  diag- 


■  Fig.  73- 
Shewing   choledocho-duodenal    anastomosis   complete,   and    gastro 
ostomy  performed. 


nosis  and  should  have  led  unerringly  to  the  conclusion  th  1 
there  musl  be  an  ulcer  of  the  duodenum  involving  the  ampulla 
of  Vater,  and  thai  in  the  course  of  cicatricial  contraction  or 
inflammatory  thickening  the  duodenal  outlet  of  the  common 
duct  had  become  occluded. 

"Confession  is  good  for  the  soul";   therefore,  permit  me  to 
-a\    thai   nol   a   thoughl   thai   duodenal  ulcer  could  possibly 


29-  Duodenal  Ulcer 

bring  about  such  a  condition  as  the  patienl  was  then  in  entered 
my  mind;  therefore,  a  guarded  diagnosis  was  rendered  of  the 
obstruction  of  the  common  duct,  probably  from  gall-stone 
impaction. 

Immediate  operation  was  advised  and  accepted.  The 
patient  was  transported  to  the  hospital  and  operation  per- 
formed at  once: 

The  Mayo-Robson  incision  for  exposure  of  the  gall-bladder 
and  ducts  was  made.  Immediately  an  enormously  distended 
gall-bladder  came  into  the  field,  thin-walled  and  tense  almost 
to  the  point  of  rupture.  Already  degenerative  spots  were  ap- 
parent, suggestive  of  gangrene  and  perforation.  Cholecys- 
tectomy seemed  imperative,  and  was  at  once  proceeded  with 
and  accomplished  without  incident.  No  calculi  were  found 
in  the  gall-bladder.  The  cystic  duct  was  double  ligated  close 
to  common  duct,  and  its  stump  covered  with  peritoneum.  The 
common  duct  was  then  carefully  palpated  and  was  found 
greatly  distended,  but  no  stone  could  be  detected.  It  was  slit 
open  and  a  small  drainage-tube  fastened  in  with  catgut  su- 
tures. At  this  point  it  was  deemed  unwise,  in  view  of  the 
precarious  condition  of  the  patient,  to  further  prolong  the 
operation,  although  it  was  fully  recognised  that  the  cause  of 
the  obstruction  had  not  been  removed.  Nevertheless,  it  was 
hoped  that  drainage  of  the  ducts  would  bring  about  a  salutary 
change  for  the  better.  In  the  next  four  weeks  the  course  of 
the  patient  was  remarkable.  The  icterus  gradually  cleared 
up  until  the  skin  resumed  its  normal  colour.  The  black 
colouration  of  the  stools  disappeared  and  they  became  white. 
The  urine  cleared  up  entirely,  and  the  bile  continued  to  pour 
from  the  wound  day  and  night.  All  this  time  the  patient  was 
developing  a  ravenous  appetite,  enjoyed  his  food  as  he  had 
not  done  for  many  months,  in  fact,  insisted  that  "we  had  given 
him  a  new  stomach." 

Under  all  these  generally  favourable  conditions,  I  was 
hoping  against  hope  that  nature  would  open  up  the  common 
duct  and  once  more  divert  the  bile  into  its  normal  channel. 

Eight  weeks  went  by  and  still  there  was  not  the  slightest 
trace  of  bile  in  the  stools.  The  patient  by  that  time  was  up 
and  about  out-of-doors  in  a  wheel-chair  daily,  and  greatly 
improved  in  ilesh  and  strength. 


The  Pathology  of  Chronic  Duodenal  Ulcer    _ 

At  this  junction  further  operative  measures  were  discussed, 
and  assented  to  by  the  patient.  April  nth,  eight  weeks  and 
three  days  after  the  first  operation,  the  wound  was  reopened, 
the  biliary  sinus  traced  down  to  the  common  duct,  which  was 
isolated  sufficiently  for  identification  and  temporarily  aban- 
doned, pending  further  exploration.  The  duodenum  was  next 
exposed  by  incising  the  peritoneum  at  its  reflection  on  to  the 
posterior  abdominal  wall  and  turning  it  (the  duodenum;  up- 
wards and  towards  the  patient's  left.  It  was  split  open  longi- 
tudinally sufficiently  to  admit  the  finger  for  exploration. 
The  ampulla  of  Vater  was  sought,  with  the  thought  of  finding  a 
stone  imbedded  therein.  The  true  state  of  matters  immedi- 
ately became  apparent.  At  the  site  of  the  ampulla  there  was 
a  deeply  excavated  round  ulcer,  surrounded  by  a  considerable 
amount  of  inflammatory  or  cicatricial  tissue  or  both.  The 
difficult  problem  presented  was  to  restore  direct  communica- 
tion between  the  common  duct  and  the  duodenum.  I  knew  of 
no  precedent  to  guide  me,  but  returned  to  the  common  duct 
and  still  further  isolated  it  from  its  surrounding  attachment-, 
and  cut  its  duodenal  end  off.  I  found  that  I  had  a  little  over 
one  inch  of  common  duct  free  and  under  control,  and  pro- 
ceeded to  implant  it  in  the  duodenum  in  a  new  place.  The 
duct  and  duodenum  came  together  readily  without  appreciable 
tension  on  either.  A  knife  puncture  was  made  through  the 
wall  of  the  duodenum  at  a  point  which  seemed  favourable  for 
implantation,  and  with  the  aid  of  two  Pagenstecher  threads 
passed  through  the  duct  and  serving  as  leaders  it  was  pulled 
through  the  opening  of  implantation  until  it  could  be  seen  well 
inside  the  mucous  membrane.  The  same  threads  were  used 
to  fasten  the  margin  of  the  opening  of  the  duet  to  the  mu- 
cous membrane.  With  a  continuous  Pagenstecher  thread  the 
muscular  wall  of  the  gut  was  folded  over  the  duet  as  repre- 
sented in  the  illustration  (Fig.  ~  :, 

The  longitudinal  wound  in  the  duodenum  was  then  closed 
in  the  usual  way. 

In  view  of  the  pathological  condition  in  the  duodenum  it 
was  deemed  wise  to  make  a  posterior  gastroenterostomy, 
which  was  immediately  proceeded  with  and  completed  withoul 
incident.     A   triplex  drainage  was  adjusted  at    the  joint   of 


294  Duodenal  Ulcer 

implantation  and  the  wound  closed.  There  was  no  further 
leakage  of. bile — the  faeces  resumed  their  natural  colour  within 
a  few  days. 

The  wound  suppurated,  but  healed  rapidly  by  granulation. 
For  the  first  few  days  the  patient  was  kept  on  rectal  aliment, 
then  little  by  little  water  and  easily  digested  fluids  were  tried 
per  mouth,  well  borne,  and  increased  until  at  the  end  of  three 
weeks  a  generous  but  simple  diet  was  being  taken  and  well 
digested  and  assimilated.  From  this  on  his  convalescence 
was  rapid  and  uneventful,  and  he  left  the  hospital  five  wreeks 
from  the  date  of  implantation.  At  the  present  writing  it  is 
one  year  since  the  implantation  and  the  gastroenterostomy. 

The  patient  has  resumed  his  usual  round  of  life,  consisting 
of  lectures,  addresses,  and  literary  work. 

A  recent  review  and  examination  shews  the  patient  in  good 
flesh,  healthy  colour,  and  he  reports  that  his  appetite  and  di- 
gestion are  all  that  can  be  asked,  and  the  stools  a  rich  yellow 
brown.  He  has  some  pain  in  the  right  hypochondrium  after 
eating  a  full  meal,  but  not  if  he  eats  lightly.  The  cicatrix  is 
weak  and  needs  constant  support  of  a  band.  Two  nodes,  one 
of  which  is  painful  and  sensitive,  are  apparent  on  either  side 
of  the  scar  at  the  upper  part.  These  are  somewhat  disquiet- 
ing because  they  are  suggestive  of  a  possible  carcinomatous 
complication. 

The  patient  thinks  that  at  one  time  since  the  operation, 
when  he  was  absent  from  his  home  on  a  lecture  tour,  he  be- 
came slightly  jaundiced,  but  it  quickly  passed  away  and  there 
has  been  no  recurrence.  At  that  time  he  was  practising  his 
vegetarian  regime,  and  living  on  almonds.  He  also  thinks 
that  at  that  time  the  stools  became  black  for  a  brief  time. 

In  neither  operation  was  there  exhibited  any  condition  of 
the  tissues  suggestive  of  carcinoma,  and  at  no  time  has  there 
been  the  slightest  evidence  of  cachexia. 

A  similar  case  is  reported  by  Francis  B.  Harrington 
("Boston  Med.  and  Surg.  Journ.,"  1909,  i,  203): 

M.  P.  Sixty-five  years  old,  a  carpenter,  who  had  always 
been  well  except   for  typhoid  fever  at  the  age  of  forty,  was 


The  Pathology  of  Chronic  Duodenal  Ulcer    295 

seized  six  months  before  coming  to  the  hospital  with  sudden 
severe  pain  in  the  right  hypochondrium.  The  pain  lasted  sev- 
eral hours  and  was  accompanied  by  vomiting.  He  became  so 
weak  that  he  went  to  bed,  where  he  remained  for  nearly  three 
months.     He  lost  thirty-three  pounds  in  weight. 

Shortly  after  the  first  attack  of  pain  he  became  some- 
what jaundiced,  and  two  weeks  later  the  faeces  became  clay- 
coloured.  He  had  two  subsequent  attacks  of  pain — one  three 
weeks  after  the  first,  the  third  ten  days  later.  The  pain  lasted 
an  hour  or  two  in  both  of  these  attacks  and  was  not  as  severe 
as  the  first  attack. 

The  subsequent  history  throws  little  light  upon  the  case. 
The  clay-coloured  stools  persisted  At  first  he  had  fever  and 
sweating. 

About  a  month  after  the  original  attack  the  patient  passed 
with  the  urine  what  the  physician  in  charge  called  blood. 
When  first  seen  six  weeks  ago  the  patient  was  markedly 
jaundiced.     The  faeces  contained  some  bile  colouring  matter. 

A  diagnosis  of  stones  in  the  common  duct  or  tumour  was 
made.  On  opening  abdominal  cavity  the  distended  gall- 
bladder and  the  bile-ducts  seemed  to  contain  no  stones.  The 
common  and  hepatic  ducts  were  greatly  distended,  being 
nearly  as  large  as  the  forefinger.  Some  hard  masses  which 
could  be  felt  near  the  duodenum  were  supposed  to  be  gall- 
stones at  the  ampulla.  By  incising  the  peritoneum  the  duo- 
denum was  exposed  on  its  posterior  surface,  and  the  duct  fol- 
lowed to  its  entrance  into  the  gut.  The  small  hard  masses 
were  found  to  be  outside  of  the  duct,  arid  proved  to  be  cal- 
careous. The  duodenum  was  opened  on  its  anterior  surface, 
which  disclosed  an  ulcer  as  large  as  a  dime,  surrounding  the 
papilla.  A  section  of  this  ulcer  was  removed  and  pronounced 
by  Dr.  Win.  F.  Whitney  to  be  non-malignant.  It  was  possible 
to  insert  a  small  probe  into  the  duct  from  the  duodenum. 
No  stone-  were  to  be  felt.  There  was  evidently  a  stricture  at 
this  end  of  the  duct.  The  duel  was  separated  from  the  portal 
veins  and  hepatic  artery  for  a  distance  of  an  inch  and  a  half. 
It  was  then  cut  across;  the  end  proximal  to  the  duodenum  was 
closed  and  inverted.     To  the  distal  end  a  small  segmented  ring 

was    attached,  and    this   end    was   re-implanted    into   the   duo- 


296  Duodenal  Ulcer 

denum  on  its  peritoneal  surface  above  the  opening  which  had 
been  made  for  examination  of  its  interior.  This  later  opening 
was  then  closed. 

The  gall-bladder  was  drained  by  a  glass  tube  to  which  a 
rubber  tube  was  attached.  A  rubber-covered  wick  was  in- 
serted for  drainage  and  the  abdomen  closed. 

The  patient  made  a  good  recovery  and  left  the  hospital 
about  three  weeks  ago.  Since  then  he  has  gained  six  or  seven 
pounds  in  weight,  and  is  feeling  in  excellent  condition. 

The  ultimate  fate  of  the  pancreatic  ducts  is,  of  course,  in 
doubt.  The  pancreas  was  of  small  size  and  did  not  surround 
the  lower  end  of  the  common  duct,  as  is  usually  the  case. 

If  the  duct  of  Santorini  has  a  separate  opening  into  the 
duodenum, — as  Schirmer  states  occurs  in  about  half  the  cases, 
— obstruction  to  the  duct  of  Wirsung  will  not  interfere  with 
the  escape  of  pancreatic  juice  into  the  duodenum. 

Dr.  P.  W.  Harrison  made  examinations  of  the  urine  and 
stool  since  recovery  from  the  operation,  with  the  following 
results: 

Urine:  Colour,  normal,  clear;  reaction,  acid;  specific  grav- 
ity, 1,012;  sugar,  none;  bile,  none;  albumin,  a  possible  trace 
(heat  and  acetic) ;  sediment,  no  red  cells;  no  casts;  Cammidge 
reaction,  negative. 

Stool :  Colour,  normal  (dark  brown) ;  odour,  normal ;  mi- 
croscopical examination,  no  excess  of  muscle-fibres,  fat,  or 
starch ;   normal  in  every  particular. 

Ferment  test  not  entirely  satisfactory.  Presence  of  a 
certain  amount  of  proteolytic  ferment  demonstrated. 

The  cicatrix  may  also  involve  the  portal  vein  in  its 
embrace,  and  so  compress  it  as  to  cause  thrombosis  or 
closure  of  it.  The  following  case  is  recorded  by  Frerichs 
("Diseases  of  the  Liver,"  i860,  i,  272,  Case  No.  30): 

Duodenal  ulcer,  cicatrisation,  partial  closure  of  ductus 
choledochus,  thrombosis  and  closure  of  the  portal  vein, 
congestion  of  lower  oesophageal  and  hemorrhoidal  veins, 
hsematemesis:    A.    Petzold,    aged    forty-one,    a   workman    of 


The  Pathology  of  Chronic  Duodenal  Ulcer    297 

robust  build,  was  quite  well  until  three  years  back,  then  had 
"indigestion"  for  thirteen  weeks,  accompanied  by  pain  in 
the  epigastrium  and  vomiting  of  yellow  masses.  These 
symptoms  disappeared  to  a  great  extent,  but  a  tenderness  of 
the  epigastric  region  remained,  which  grew  worse.  Eight 
weeks  ago  began  to  have  symptoms  of  hemorrhoidal  conges- 
tion. On  January  17th  the- patient  vomited  Y2  quart  of  dark 
blood.  Two  subsequent  attacks  of  hsematemesis  occurred 
on  the  same  day;  two  attacks  on  the  19th;  increasing  col- 
lapse; death  on  the  24th.  On  section  stomach  contained 
about  2  lbs.  of  clotted  blood;  1 3^2  inches  from  the  cardia  there 
were  varicose  veins  filled  with  firm  clots.  In  the  duodenum, 
%  inch  beyond,  was  a  flattened  ulcer  |  inch  in  diameter,  in 
the  centre  of  which  was  a  small  opening  of  about  the  size  of  a 
pin's  head,  which  led  into  a  tubular  opening  about  34  inch 
deep,  and  directed  towards  the  middle  line.  Surrounding  this 
channel  was  a  quantity  of  new-formed  connective  tissue,  by 
the  contraction  of  which  the  ductus  choledochus  was  narrowed 
and  the  portal  vein  entirely  closed.  In  the  anterior  wall  of 
the  portal  vein  was  a  thrombus  showing  softening  in  the  centre. 
The  thrombosis  extended  into  the  right  and  left  branches  of 
the  portal  vein  into  the  liver. 

In  a  "System  of  Medicine,"  by  Clifford  Allbutt  and 
H.  I).  Rolleston  (second  edition,  iii,  559),  it  is  written: 
"Dr.  French  recorded  thrombosis  of  the  portal  vein 
from  compression  of  this  vessel  as  a  direct  result  of  deep 
cicatrisation  of  a  duodenal  ulcer."  I  have  not  been 
able,  in  spite  of  diligent  search,  to  trace  the  original 
reference. 

As  the  ulcer  increases  in  age  it  invades  more  deeplj 
the  wall  of  the  duodenum.  The  thickening  which  Is 
found  in  the  base  of  the  ulcer,  the  thick  white  deposil 
in  and  beneath  the  serosa,  and  the  omental  adhesions 
growing  firmly  to  the  outer  side  of  the  bowel  are  all 
evidence  of  the  measures  taken  to  prevent  the  complete 


298  Duodenal  Ulcer 

penetration  of  the  wall  of  the  gut;  they  are  protective 
measures.  In  spite  of  them,  as  we  know.,  the  ulcer  may 
burst  through  all  the  coats,  and  a  "perforation"  of  the 
intestine  results.  But  if  the  ulcer  should  lie  in  that  part 
of  the  bowel  normally  in  contact  with  the  pancreas,  this 


Fig.  74. — Perforating  Ulcer  of  the  Duodenum. 

The  first  part  of  a  duodenum  with  the  adjacent  portion  of  the  stomach, 
shewing  just  beyond  the  pyloric  ring  a  small  perforating  ulcer,  the  edge 
of  which  is  abrupt  and  measures  one-third  of  an  inch  in  thickness.  The 
perforation  in  the  serous  coat  is  considerably  smaller  than  the  opening 
upon  the  mucous  surface.  On  the  reverse  of  the  specimen  the  peritoneum 
beneath  the  ulcer  is  seen  to  be  thickened. 

From  a  middle-aged  man  who  had  long  suffered  from  dyspepsia  with 
pain  in  the  epigastrium.  He  was  suddenly  seized  with  acute  symptoms 
and  died  twelve  hours  afterwards.      (Guy's  Hosp.  Museum,  No.  743.) 

gland  may  be  invaded  as  soon  as  all  the  thickness  of  the 
duodenum  is  destroyed.  A  deep,  ragged  excavation 
may  be  found  in  the  pancreas,  which  now  actually  forms 
the  base  of  the  ulcer.  In  museum  specimens,  and 
occasionally  during  operations,  the  deep  erosion  and 
excavation  of  the  pancreas  are  seen  or  felt,  and  a  cavity 


The  Pathology  of  Chronic  Duodenal  Ulcer    299 

large  enough  to  hold  a  walnut  may  be  formed.  If  this 
invasion  occupies  the  head  of  the  gland,  the  common 
bile-duct  or  the  canal  of  Wirsung  may  be  opened.  Speci- 
men 90  D,  in  St.  George's  Hospital,  shews  the  com- 
mon bile-duct  ulcerated  through  the  upper  and  lower 


1  '""■•  75- — Large  Di  odenal  Ulcer,  Eroding  the  Pancreas  and  Opening 
1  hi    Common  Bile-duct. 

From  the  body  of  a  man  aged  forty-one.  The  base  of  the  ulcer  has 
exposed  the  pancreas  and  has  ulcerated  through  the  common  bile-duct, 
into  the  proximal  and  distal  ends  of  which  glass  rods,  are  passed.  The 
Stomach  and  duodenum  were  much  dilated.  The  patient  was  admitted 
for  abdominal  pain  and  haematemesis.  (St.  George's  Hosp.  Museum, 
No.  90  D.) 

divided  ends,  being  seen  in  the  base  of  the  ulcer.  In 
like  manner  the  liver  may  be  found  in  the  floor  of  the 
ulcer,  which  has  by  degrees  become  adherent  to  the 
under  surface  of  the  liver,  to  the  inner  side  of  the  gall- 
bladder. In  thi>  steady  destruction  of  the  walls  of  the 
duodenum    the   structures   lying    therein    may    become 


300  Duodenal  Ulcer 

involved.  Chief  among  these  are  the  various  blood- 
vessels, which  may  have  their  walls  eroded.  Every 
vessel,  artery,  or  vein  lying  near  the  duodenum  may  be 
implicated;  death  may  instantly  result  from  the  profuse 
haemorrhage  which  occurs  upon  the  destruction  of  the 
vessel  wall.  The  gastro-duodenal  artery,  or  a  branch 
of  it,  is  that  msot  often  opened ;    the  pancreatico-duo- 


Fig.  76. — Ulceration  with  Erosion  of  Arteries. 

Part  of  the  duodenum  with  the  pyloric  end  of  the  stomach  laid  open. 
Close  to  the  pylorus  is  seen  an  old  ulcer,  the  size  of  a  shilling,  with  round 
edges  and  incurved  mucous  membranes.  The  pancreas  is  exposed  in  the 
base  of  the  ulcer  and  a  branch  of  the  pancreatico-duodenal  artery  has  been 
opened.  The  ulcer  is  quadratical  in  form.  At  its  lower  end  there  has  been 
a  more  recent  superficial  extension  of  the  ulceration  to  the  apparent  right. 
At  the  upper  end  there  has  been  a  separation  of  the  adhesion  between  the 
pancreas  and  pylorus,  making  an  opening  in  the  floor  of  the  ulcer  at  this 
spot  (?  p.  m.).     (London  Hospital  Museum,  Spec.  No.  1 1 51 .) 

denal  is  given  as  the  source  of  the  haemorrhage  in  more 
than  half  the  recorded  cases.  In  all  the  fatal  cases  I 
have  examined  the  same  conditions  have  been  disclosed. 
The  artery  has  thick,  rigid  walls,  and  as  it  lies  in  the 
hard,  fibrous  base  of  the  ulcer,  an  opening  has  been 
eaten  through  the  side.  Nothing  would  appear  to  be 
more  hopeless  than  the  closure  of  such  an  opening,  for 


The  Pathology  of  Chronic  Duodenal  Ulcer    301 

the  vessel  is  so  rigid  and  the  ulcer  so  unyielding  that 
neither  contraction  nor  retraction  are  possible.  The 
artery  stands  up  stiffly,  its  lumen  wide  open  to  the 
blood-stream.  A  clot  which  formed  in  the  erosion 
could  hardly  withstand  the  strong  current  of  the  blood. 
The  gastro-duodenal,  the  right  gastro-epiploica,  and  the 
pancreatico-duodenal  have  all  been  opened  in  so  many 
instances  that  specific  quotation  of  any  case  is  unneces- 
sary. Perry  and  Shaw  (page  203)  write:  "In  one 
case  haemorrhage  was  preceded  by  the  formation  of  a 
small  aneurysm  of  the  eroded  artery,  resembling  the 
aneurysms  on  the  pulmonary  artery  so  often  found  in 
cases  of  fatal  haemoptysis  from  phthisis."  In  a  few 
records  it  is  noted  that  there  was  "aneurysmal  dilatation" 
of  the  vessel  at  the  point  of  rupture.  In  one  case  the 
hepatic  artery  was  eroded.  The  record  is  given  by 
Broussais  ("Sur  la  duodenite  chronique,"  Thesis  de 
Paris,   1825,  p.  65): 

("(Mint  R..  aged  sixty-two,  strong  constitution,  had  habitu- 
ally taken  emetics  and  purgatives  tor  his  rheumatism.  Now 
experienced  digestive  disturbances  and  eructations.  Con- 
tinued for  two  years.  Arm  was  then  amputated  owing  i<>  a 
cancerous  growth.  The  wound  healed  well,  but  he  began  to 
have  pain  in  tin-  gastric  region.  On  the  tenth  day  alter  the 
operation  he  was  seized  with  faintness,  general  rigor,  convul- 
sions, pallor,  cold  extremities,  and  death  occurred.  On 
section,  intestinal  tract  tilled  with  clumps  of  blood;  ulcer  in 
the  firsl  part  of  the  duodenum,  which  had  commenced  t<> 
cicatrise.  At  the  base  of  the  ulcer  was  the  hepatic  arterj 
ned  up.  The  pyloric  end  of  the  stomach  was  somewhat 
red,  the  L'tit  healths',  liver  granular  and  almosl  bloodless. 

In  two  cases  the  aorta  has  been  opened:    one  case  is 
recorded  by  Stich  and  one  by  Griinfeld. 


302  Duodenal  Ulcer 

I.  Duodenal  ulcer  with  perforation  into  the  abdominal 
aorta.  (Stich,  E.:  "Archiv  f.  klin.  Med.,"  1874,  xiii,  191): 
Female,  very  old,  suffering  from  severe  bronchial  catarrh, 
suddenly  vomited  blood  (February  6th).  The  vomiting 
ceased  for  a  short  time  after  injections  of  ergotin,  but  there 
were  repeated  attacks  until  death  from  exhaustion  occurred 
on  February  24th. 

On  post-mortem  examination  a  "terraced"  ulcer  about  the 
size  of  a  "Groschen"  was  found  on  the  duodenum.  At  the 
base  of  the  ulcer  wras  seen  a  perforation  which  admitted  a 
medium-sized  sound.  This  led  directly  into  the  aorta,  about 
5  cm.  above  its  bifurcation;  the  internal  surface  of  the  aorta 
shewed  extensive  atheromatous  degeneration,  and  a  round, 
atheromatous  ulcer  not  quite  the  size  of  a  Kreutzer  was  situ- 
ated at  the  site  of  the  perforation.  The  perforated  process 
had  originated  in  the  duodenum;  its  outer  wall,  corresponding 
to  the  whole  extent  of  the  ulcerative  process,  was  firmly 
adherent  to  the  aorta.  Perforation  of  the  aorta  had  un- 
doubtedly occurred  by  February  6th.  The  fact  that  death 
was  not  instantaneous  as  a  result  of  the  haemorrhage  was  dus 
to  the  presence  of  a  clot,  which  probably  had  formed  rapidly, 
owing  to  weakening  of  the  heart's  action,  and  partially  oc- 
cluded the  opening. 

II.  Case  of  perforated  ulcer  situated  at  the  duodeno- 
jejunal angle,  opening  into  the  aorta  (Griinfeld,  F.:  Case 
quoted  in  "Schmidt's  Jahrbiicher,"  1883,  cxcviii,  143):  Man, 
aged  fifty-six,  had  been  laid  up  for  nineteen  weeks  with  a 
fractured  femur.  Had  suffered  from  cough  ever  since  he 
could  remember,  with  frequent  blood-streaked  sputum. 
During  the  last  year  had  become  very  emaciated.  Had  pain 
and  tenderness  in  stomach  region.  On  February  26th  he  had 
a  sudden  attack  of  hamatemesis  and  subsequent  melama. 
This  did  not  return  until  March  5th,  when  he  had  a  second 
attack  of  profuse  haematemesis.     Died  in  twenty  minutes. 

Post-mortem  examination :  The  stomach  was  completely 
filled  by  black  blood-clot.  The  mucosa  was  somewhat 
swollen,  but  shewed  no  ulceration.  The  duodenum  also 
contained  dark  blood,  partly  clotted,  partly  fluid.  In  the 
duodeno- jejunal  flexure  wras  seen  a  large  area  of  ulceration 


The  Pathology  of  Chronic  Duodenal  Ulcer    303 

with  circular  indurated  margins,  which  penetrated  through 
the  mucosa  and  was  adherent  to  the  neighbouring  tissues  and 
the  aorta  at  the  level  of  the  first  lumbar  vertebra.  Between 
the  perforation  and  the  aorta  a  large  cavity  was  found  in  the 
connective  tissue,  the  walls  of  which  were  formed  by  partially 
organised,  fibrin-coagulated  blood.  From  this  cavity  a  fine 
opening,  easily  admitting  a  sound,  led  directly  into  the  aorta. 
At  the  part  of  the  aorta  thus  affected  there  was  no  trace  of 
aneurysm.  In  the  large  intestine  were  two  irregular,  super- 
ficial ulcers  with  everted  edges.  The  lungs  shewed  old  case- 
ated  infiltration  and  marginal  emphysema.  The  coronary 
arteries  were  atheromatous. 

Two  cases  of  perforation  of  the  portal  vein  are  recorded 
by  Habershon  and  Rayer: 

I.  Ulceration  of  the  duodenum,  perforation  into  portal 
vein,  haemorrhage  (S.  O.  Habershon,  M.D.:  "Trans.  Path. 
Soc.  Lond.,"  1876,  xxvii,  155):  Celina  T.,  aged  thirty,  ad- 
mitted into  Guy's  Hospital  September,  1875.  Had  a  mis- 
carriage in  July,  and  from  that  time  had  suffered  from  pains 
in  her  side.  Three  weeks  before  admission  she  had  severe 
rigors,  which  lasted  six  hours.  A  fortnight  later  she  vomited 
about  3  pints  of  blood.  On  admission  patient  was  emaciated 
and  anaemic;  there  was  much  abdominal  pain  and  distension. 
Hemorrhage  from  the  stomach  recurred  on  September  19th 
and  again  on  October  16th.     She  shortly  afterwards  sank. 

On  post-mortem  examination  there  was  a  large  ulcer  with  a 
depressed  circular  margin  in  the  duodenum  about  one  inch 
from  the  pylorus.  On  the  side  towards  the  fissure  of  the  liver 
there  was  a  large  sloughing  excavation.  The  ulceration  and 
sloughing  had  entirely  destroyed  the  common  bile-duet  and 
the  hepatic  duct.  The  portal  vein  was  laid  bare,  and  an  irregu- 
lar ulceral  ive  opening  was  presenl  in  it  just  above  the  pancreas, 
from  which  fatal  haemorrhage  had  occurred.  The  adjoining 
part  ot  the  liver  contained  an  irregular  abscess  ami  there  were 
several  smaller  ones  in  the  organ.  There  was  some  general 
peritonitis  and  a  collection  of  pus  in  the  pelvis. 

II.  Gall-stones,    hepatic    ulceration,    destruction    ot    gall- 


304  Duodenal  Ulcer 

bladder,  perforation  of  portal  vein,  perforation  in  duodenum 
and  hepatic  flexures  of  colon  (Rayer,  P.:  "Archives  generate 
de  Medecine,"  1825,  vii,  161):  Madame  P.,  aged  fifty-six,  had 
always  suffered  from  constipation.  This  occasionally  lasted 
as  long  as  fifteen  days.  For  the  last  six  years  has  been  troubled 
with  digestive  disturbances.  Abdomen  sometimes  distended; 
indiscretions  in  diet  produced  exacerbations  of  pain  round  the 
umbilicus.  On  one  occasion,  after  taking  a  hip  bath,  she  had  a 
sudden  severe  attack  of  colic.  She  fainted  and  had  at  the 
same  time  large  evacuations  consisting  of  black  clots  floating 
in  blood-stained  fluid;  signs  of  collapse  ensued  and  death 
occurred  in  twenty-four  hours. 

On  post-mortem  examination  the  stomach  was  large  and 
distended.  Its  pyloric  extremity  was  adherent  to  the  liver. 
The  hepatic  flexure  of  the  colon  was  likewise  adherent  to  the 
liver.  The  gall-bladder  had  been  destroyed.  In  the  position 
corresponding  to  it  was  an  ulcerated  cavity  which  contained  a 
gall-stone  about  8  lines  in  diameter.  It  was  granulated  out- 
side and  lying  free  in  the  cavity.  This  cavity  communicated 
with  the  duodenum  through  a  perforation,  and  there  was  also 
a  perforation  into  the  colon.  There  were  also  two  perfora- 
tions in  the  portal  vein. 

In  one  case  the  superior  mesenteric  vein  was  opened. 

Case  of  pylephlebitis  suppurativa  (Warfvinge:  "Schmidt's 
Jahrb.,"  1882,  cxcv,  130):  Woman,  aged  forty-five,  admitted 
October  15,  1881,  suffering  from  abdominal  pain,  chills,  and 
sweats.  Temperature  varied  between  370  and  410  C.  No 
vomiting  of  blood  or  melaena.  Gradually  became  jaundiced; 
bile-pigments  appeared  in  the  urine.  Urine  contained  albu- 
men and  pus.  Patient  gradually  became  comatose  and  died 
November  1st. 

On  post-mortem  examination,  faint  icteric  tinge  of  skin; 
oedema  and  hypostasis  of  lungs;  enlargement  and  softening 
of  spleen;  liver  enlarged  and  parenchyma  soft  and  greenish- 
yellow  in  colour.  Several  of  the  smaller  branches  of  the  portal 
vein  obliterated  by  thrombi;  in  the  porta  hepatica  there  were 
masses  of  thrombi  of  firm  consistence  adhering  to  the  walls. 


The  Pathology  of  Chronic  Duodenal  Ulcer    305 

The  main  trunk  of  the  portal  vein  was  thickened  and  filled 
with  reddish-grey  masses  of  clot  resembling  thick  pus  in 
consistence.  The  splenic  vein  was  normal,  but  the  superior 
mesenteric  vein  was  filled  with  numerous  thrombi  adherent 
to  the  intima.  In  the  interior  of  the  superior  mesenteric 
vein  there  were  two  perforations.  One  perforation  led  into  a 
small  abscess  cavity  with  irregular  walls,  lying  between  the 
portal  vein  and  the  inferior  horizontal  portion  of  the  duodenum. 
This  cavity  was  filled  with  a  reddish-grey  fluid  and  did  not 
communicate  with  any  other  organ.  The  second  perforation 
was  situated  at  the  junction  of  a  large  mesenteric  branch 
with  the  superior  mesenteric  vein.  This  led  into  the  duode- 
num and  opened  at  the  base  of  a  duodenal  ulcer  in  the  anterior 
and  upper  surface  of  the  inferior  horizontal.  The  ulcer 
was  roughly  circular  and  1.5  cm.  in  its  widest  diameter;  the 
edges  were  irregular;  the  loss  of  substance  affected  principally 
the  mucous  coat;   the  muscularis  was  less  affected. 

Remarks:  The  absence  of  ascites  was,  in  Warfvinge's 
opinion,  due  to  the  fact  that  the  portal  vein  was  not  entirely 
obliterated.  The  case  is  also  noteworthy  because  of  the 
unusual  position  of  the  duodenal  ulcer  below  the  opening  of 
the  bile  and  pancreatic  ducts  in  the  horizontal  portion. 

When  the  base  of  the  ulcer  is  completely  destroyed,  a 
fistula  may  be  formed  between  the  duodenum  and  any 
viscus  to  which  it  has  become  adherent.  The  most 
frequent  form  met  with  involves  the  gall-bladder  and  the 
duodenum  (cholecysto-duodenal  fistula);  but  it  is  prob- 
able that  in  the  great  majority  of  the  cases  the  perfor- 
ation is  the  result  of  cholelithiasis  and  has  started  from 
the  gall-bladder.  In  the  various  London  museums  are 
several  specimens  illustrating  this,  and  in  two  the  fistula 
had  allowed  the  passage  of  a  gall-stone,  which  later 
became  impacted  in  the  ileum  and  caused  death.  It 
must,  1  think,  be  assumed  thai  the  gall-bladder  has  been 
the  starting-point  in  all  cases  in  which  a  dear  history  of 


306 


Duodenal  Ulcer 


duodenal  ulcer  is  not  to  be  obtained.  In  the  very  great 
majority  of  recorded  cases  of  cholecysto-duodenal  fistula 
the   gall-bladder   has    been    small,    sclerosed,    and    gall- 


Fig.  77. — Pancreaticoduodenal  Fistula. 

A  duodenum  with  the  pancreas  and  a  part  of  the  stomach  mounted  to 
shew  a  communication  between  the  duodenum  and  a  cavity  in  the  head  of 
the  pancreas,  which  in  the  recent  state  contained  blood-clot.  The  per- 
foration is  situated  on  the  concave  border  of  the  duodenum,  two  inches 
below  the  pyloric  ring,  and  an  inch  and  a  half  above  the  biliary  papilla. 
Histological  examination  of  the  walls  of  the  cavity  in  the  pancreas  shews 
an  excess  of  fibrous  tissue  between  the  acini  of  the  gland,  but  no  evidence 
of  malignant  growth. 

Lizzie  C,  set.  twenty-nine,  was  admitted  under  Dr.  Hale  White  lor 
severe  haerhatemesis  and  melaena,  which  began  eight  days  before  admission. 
Five  days  later  an  exploratory  laparotomy  was  performed,  but  the  source 
of  haemorrhage  was  not  discovered.  She  died  on  the  following  day. 
(Guy's  Hosp.  Museum,  No.  757.) 


stones  have  been  present  within  its  lessened  cavity,  or 
a  stone  has  been  fixed  in  the  cystic  duct.  In  all  the 
cases  but  one  related  by  Perry  and  Shaw  there  can  be  no 


The  Pathology  of  Chronic  Duodenal  Ulcer    307 

doubt  that  the  perforation  occurred  into  the  duodenum 
from  the  gall-bladder.  The  one  case  in  which  a  duodenal 
ulcer  was  probably  the  origin  of  the  fistula  is  the  follow- 
ing: 


Fig.  78. — Chronic  Ulcer  of  the  Duodenum  Eroding  the  Pancreas. 
The  firsl  four  inches  of  a  duodenum,  seen  from  behind,  with  a  portion 

of  the  pancreas  to  which  it  is  adherent.  There  i-  a  large  oval  ulcer  with 
thin,  clean-cut  edges,  the  greater  diameter  of  which  corresponds  to  the 
long  axis  ot  the  intestine  and  measures  about  two  inches.  The  floor  of 
the  ulcer  is  formed  by  the  head  of  the  pancreas,  and  in  it  is  exposed  the 
divided  end  of  the  superior  pancreatico-duodenal  artery,  indicated  l>'  .1 
rod. 

Thomas  I..,  a-! .  sixty,  was  admitted  under  Mr.  Golding-Bird  for  a  severe 
injury  to  the  leg,  for  which  amputation   was  performed.      lie  died  eleven 
da\s  after  the  operation  with  symptoms  of  severe  internal  hsemorrh 
At    the  autopsy  much  blood   was  found   in   the  intestines.      (Guy's   Hosp. 
Museum,  No.  737 

Cholecysto-duodenal  fistula ;  ulcers  of  duodenum :  C.  W.  I  . , 
a  female,  aged  twenty-five,  died  from  haematemesis,  from 
recurrenl  attacks  of  which  she  suffered  during  the  lasl  six 
weeks  of  her  life.  She  was  also  jaundiced.  Al  the  autops} 
the  gall-bladder  w.h  seen  i<>  be  adherent  t<>  the  duodenum, 
.ind  communicated  with  it  by  a  >inu>  lull  an  inch  long  and  .1 


308  Duodenal  Ulcer 

quarter  oi  an  inch  in  diameter.  Around  the  opening  of  the 
sinus  into  the  duodenum  the  mucous  membrane  was  ulcerated, 
and  there  were  several  other  ulcers  adjacent  to  it.  There  was 
a  primary  malignant  growth  in  the  common  duct  and  sec- 
ondary deposits  in  the  liver.  ("Path.  Soc.  Trans.,"  1857, 
i\,  220.) 

The  earliest  case  recorded  is  given  by  Long,  of  Liver- 
pool, in  the  paper  in  which  for  the  first  time  he  recorded 
the  occurrence  of  duodenal  ulcer  in  cases  of  burns.  The 
following  is  a  brief  abstract  of  the  case,  which  is  given 
more  fully  elsewhere  (Long:  "London  Med.  Gazette," 
1840.  vol.  xxv  (new  series,  vol.  i),  741): 

Duodenal  ulcer  due  to  burns;  fistula  between  the  duodenum 
and  the  gall-bladder:  Anna  Jones,  aged  twenty-eight,  pre- 
viously healthy,  was  extensively  burned.  Then  had  tender- 
ness in  epigastrium  and  frequent  vomiting;  intense  thirst 
and  constipation.  Death  eight  days  afterwards.  On  section 
stomach  shewed  in  the  upper  corner  of  the  duodenum  an 
ulcer  as  big  as  a  shilling,  whose  edges  were  loosely  adherent 
to  the  gall-bladder.  At  this  spot  the  gall-bladder  was  soft 
and  eroded.     Two  smaller  ulcers  were  found  in  the  duodenum. 

Hoffman  ("Schmidt's  Jahrbiich.,"  cxxxix,  293)  relates 
briefly  the  following  case: 

Woman,  sixty-three  years  of  age,  who  had  an  ulcer  in  the 
tirst  portion  of  the  duodenum.  Plastic  peritonitis  was  found 
round  the  base  of  the  ulcer,  and  the  common  bile-duct  was 
occluded  thereby;  the  biliary  channels  behind  the  obstruction 
were  all  greatly  dilated,  and  a  fistula  was  found  between  the 
distended  gall-bladder  and  the  base  of  the  ulcer. 

Another  interesting  example  is  the  following: 

Perforated  duodenal  ulcer;  adhesion  with  gall-bladder; 
fistula  between  duodenum  and  gall-bladder  ("Lancet,"  1850, 
i,    7761:     Woman,   aged    twenty-five;    suffered   latterly   from 


The  Pathology  of  Chronic  Duodenal  Ulcer    309 

haematemesis  and  melaena;  very  anaemic;  jaundiced;  liver 
enlarged  and  tender.  On  post-mortem  examination  the 
stomach  presented  a  healthy  appearance,  but  on  opening 
the  duodenum  several  ulcers  were  discovered  at  a  distance  of 
between  one  and  two  inches  from  the  pylorus.  One  of  these, 
situated  on  the  upper  wall,  had  perforated  the  intestine  by  a 
round  opening,  about  a  quarter  of  an  inch  in  diameter,  with 
smooth,  rounded  edges,  this  aperture  corresponded  to  a  similar 
opening  in  the  gall-bladder,  the  two  organs  having  been 
united  by  adhesions  at  this  point.  Two  or  three  small  and 
superficial  ulcerations  existed  in  the  neighbourhood  of  this 
abnormal  connexion,  and  immediately  opposite,  on  the  lower 
wall  of  the  bowel,  there  was  an  irregular,  oval  ulceration,  of 
similar  character,  having  an  area  of  about  half  an  inch,  and 
close  below  this  spot  the  free  edge  of  one  of  the  valvulae  con- 
niventes  was  ulcerated  for  the  length  of, half  an  inch. 

A  case  is  recorded  by  Reinhold  ("Munch,  med. 
W'och.,"  1887,  i,  678)  in  which  hepatic  abscess  had  formed 
as  a  result  of  a  duodenal  ulcer.  A  fistula  between  the 
gall-bladder  and  the  duodenum  was  present,  which  was 
due,  it  would  seem  to  me,  to  the  blocking  of  the  cystic 
duct  and  to  the  distension  of  the  gall-bladder,  both  of 
which  are  mentioned  in  the  report. 

In  one  case  in  my  own  series  a  fistula  readily  admit- 
ting the  tip  of  the  linger  was  found.  There  was  a  long 
history  of  duodenal  ulcer,  and  the  gall-bladder  was 
otherwise  healthy;  there  were  no  stones  No.  8i  in  case 
li-i ).  hi  many  other  cases  of  mine  the  gall-bladder  has 
been  very  closely  adherent  to  the  duodenum. 

Two  cases  of  duodeno-colic  fistula  are  recorded;  one 
by  Sanderson    "Path.  Soc.  Trans.,"  1X02,  \i\ .   17; 

J .  S.,  a  male  aged  thirty,  was  admitted  into  the  Middlesex 
Hospital  under  Dr.  Stewarl  for  epigastric  pain  and  vomiting 


310  Duodenal  Ulcer 

of  fifteen  years'  duration.  He  had  suffered  from  four  similar 
attacks,  the  first  of  which  had  occurred  four  years  before  his 
admission.  On  the  present  occasion  the  symptoms  continued 
for  fourteen  days,  when  he  died,  and  at  the  autopsy  the 
stomach  and  first  part  of  the  duodenum  were  much  distended. 
Three-quarters  of  an  inch  from  the  pylorus  and  on  the  pos- 
terior wall  there  was  a  pouch  as  large  as  a  pigeon's  egg  pro- 
jecting from  the  duodenum,  the  lining  of  which  wras  smooth  and 
formed  of  fibrous  tissue.  The  hinder  wall  of  the  pouch  was 
firmly  adherent  to  the  head  of  the  pancreas,  and  its  anterior 
and  lower  part  attached  to  the  transverse  colon,  with  which 
it  communicated  by  a  valvular  aperture  large  enough  to  admit 
a  swanquill.  There  was  no  evidence  of  growth,  and  no 
other  disease  was  found  in  the  body  except  a  small  tuberculous 
cavity  at  the  apex  of  the  right  lung. 

A  second  case  is  related  by  Perry  and  Shaw  (Case 
258,  p.  284): 

George  N.,  aged  twenty-five,  was  admitted  under  Mr. 
Cooper  Foster  with  a  lumbar  and  psoas  abscess,  from  the 
effects  of  which  he  died. '  He  had  been  in  the  hospital  two 
years  previously  under  Dr.  Wilks,  with  an  irregular  lump  in 
the  epigastric  region  which  was  thought  by  some  to  be  caseous 
omentum.  At  the  autopsy  several  vertebrae  were  found  to 
be  carious,  and  the  lumbar  and  mesenteric  glands  were  caseous. 
The  stomach  was  slightly  lardaceous  and  adherent  to  the 
transverse  colon.  Immediately  beyond  the  pyloric  ring  was 
a  small  opening  in  the  duodenum  which  led  into  a  fistula,  and 
this  opened  straight  into  the  colon.  The  transverse  colon 
was  at  the  part  irregular  on  the  surface,  and  shewed  a  large, 
old„ healed  ulcer  going  round  the  circumference  of  the  bowel, 
and  a  little  lower  down  was  a  similar  but  larger  patch,  4  or  5 
inches  long.  There  was  no  other  ulceration  in  the  intestine 
and  no  tubercle.  The  intestine  was  extremely  lardaceous 
all  through.  The  liver,  spleen,  and  kidneys  were  lardaceous. 
The  gall-bladder  was  normal. 

A  few  cases  are   found    recorded   in   the  literature  in 


The  Pathology  of  Chronic  Duodenal  Ulcer    311 

which  a  fistula  between  the  duodenum  and  the  stomach 
was  found;  but  in  all  the  explanation  given  by  the 
recorders,  that  the  ulcer  had  its  origin  in  the  stomach,  is 
very  probably  correct.  I  can  find  no  reference  to  a  case 
in  which  the  fistula  seemed  to  begin  from  the  duodenal 
side.  Cases  of  external  fistulae  also  occur.  Instances 
are  quoted  in  the  chapter  dealing  with  perforating  ulcers. 
Ulcus  Carcinomatosum. — We  are  now  well  informed 
of  the  fact  that  chronic  ulcer  of  the  stomach  in  a  certain 
proportion  of  cases  leads  to  the  development  of  malig- 
nant disease.  Cancer  of  the  stomach  would  appear  to 
begin  in  connexion  with  a  chronic  ulcer  in  something 
over  60  per  cent,  of  cases.  This  is  the  estimate  given 
by  W.  J.  Mayo  as  a  result  of  the  examination  of  a  large 
number  of  specimens  removed  during  the  operation  of 
partial  gastrectomy,  and  it  coincides  with  that  which 
has  been  made  by  other  observers,  on  both  clinical  and 
pathological  grounds.  It  is  a  curious  and  at  present 
inexplicable  thing  that  a  change  from  a  simple  to  a 
malignant  condition  in  the  duodenum  is  of  extreme 
rarity.  Chronic  duodenal  ulcer,  so  far  as  concerns  the 
cases  coming  to  the  surgeon  for  relief,  is  a  more  frequenl 
disorder  than  ulcer  of  the  stomach.  Cancer  of  the 
duodenum  is  very  rarely  -ecu;  cancer  of  the  stomach  is, 
unhappily,  very  common.  W.  J.  Mayo  writes  ("Journ. 
Amer.  Med.  Assoc,"  190s.  ii,  558):  "We  have  seen 
but  four  apparentlj  primary  carcinomata  of  the  duo- 
denum. In  two  of  these  origin  was  uncertain,  and  in 
bin  one  did  it  seem  probable  thai  the  cancer  had  devel- 
oped in  an  ulcer.  In  five  cases,  however,  we  have 
known  gastric  cancer  to  develop  <>n  the  edge  of  .1  duo- 


312  Duodenal  Ulcer 

denal  ulcer  which  involved  the  stomach  at  the  pyloric 
ring."  E.  A.  Codman  has  had  the  same  experience, 
and  he  raises  the  interesting  question  as  to  whether 
this  sequence  of  events  may  not  be  more  common  than 
we  suppose,  seeing-  that  duodenal  ulcer  is  frequent, 
pyloric  ulcer  rare ;  pyloric  cancer  frequent,  and  duodenal 
cancer  rare.  I  have  met  with  only  two  cases  of  car- 
cinoma limited  to  the  duodenum;  in  one  there  was  no 
history  of  chronic  ulceration;  in  the  second  the  recur- 
rence of  perfectly  characteristic  "attacks"  over  a  long 
period  made  the  diagnosis  of  duodenal  ulcer  extremely 
probable;  at  the  operation  a  malignant  growth,  strictly 
limited  to  the  first  and  a  part  of  the  second  portion  of 
the  duodenum,  was  found. 

Case  i. — September,  1901.  S.  F.,  female,  aged  fifty-three. 
(Was  sent  by  Dr.  Lockwood,  Halifax.)  Was  in  fair  health 
up  to  two  months  ago,  when  she  began  to  lose  flesh,  and  to 
have  persistent  vomiting  and  great  discomfort  after  meals. 
No  blood  was  vomited  and  there  was  no  melsena.  At  the 
operation  a  scar  of  an  old  ulcer  was  found  in  the  duodenum. 
In  the  hinder  wall  of  the  first  and  second  parts  of  the  duo- 
denum a  hard,  craggy  mass  was  felt  involving  also  the  head 
of  the  pancreas.  Several  glands  were  felt  above  the  pancreas. 
( '.astro-enterostomy  was  performed  with  temporary  benefit. 
A  post-mortem  examination  subsequently  disclosed  an  old 
scar  in  the  first  part  of  the  duodenum  on  the  anterior  wall. 
Opposite  to  this,  and  extending  into  the  second  part  of  the 
duodenum,  was  a  large  ulcerating  growth  which  had  eaten  in  in 
the  pancreas.  It  was  thought  to  have  started  in  an  ulcer 
immediately  opposite  the  healed  scar  in  the  first  part. 

(asp:  2. — S.  S.,  male,  aged  fifty-four.  (Sent  by  Dr.  Ellis, 
Halifax.)  For  ten  years  has  had  persistent  gastric  trouble^, 
pain  after  food,  vomiting,  blood-stained  at  times,  and  mela?na. 
Has  lost  weight  steadily  in  last  few  months  and  is  now  ex- 
tremely  thin  and  pinched.     The  stomach  is  largely  dilated. 


The  Pathology  of  Chronic  Duodenal  Ulcer    313 

At  the  operation  a  large  mass  was  felt  involving  the  pylorus, 
the  duodenum,  and  the  head  of  the  pancreas.  The  patient 
died  in  three  weeks.  At  the  autopsy  a  chronic  ulcer  of  the 
duodenum  was  found.  Most  of  the  circumference  was  occu- 
pied by  large  nodular  masses  of  carcinoma  which  invaded  the 
pancreas  also.  The  portion  of  the  ulcer  nearest  the  pylorus 
was  thick  and  stiff,  but  no  malignancy  was  discovered  in  it. 

A  very  few  cases  are  recorded  in  the  literature.  Perry 
and  Shaw  (pp.  274,  275,  276)  give  notes  of  five  cases  of 
"simple  ulcers  becoming  malignant."  There  are  only 
two  of  them  in  which  there  would  seem  to  be  any  positive 
connexion  between  a  chronic  ulcer  and  the  growth  which 
was  found  at  autopsy.     The  following  are  the  cases: 

I.  Charles  L.,  aged  forty-five,  was  admitted  under  Dr. 
Habershon  and  died  eleven  days  later.  Xo  clinical  account 
is  preserved.  At  the  autopsy  the  stomach  was  enlarged  and 
the  omentum  was  adherent  to  the  pylorus.  A  puckering  of 
tin-  tissues  was  seen  at  this  part.  On  handling  the  pylorus  a 
hard  lump  was  felt  which  was  composed  of  the  diseased 
pylorus  with  some  enlarged  lymphatic  glands  and  the  head  of 
the  pancreas.  The  latter  had  in  it  a  caseous  mass  about  the 
size  of  a  walnut.-  This  and  the  small  cancerous  lymphatic 
glands  could  be  dissected  away  from  the  intestine,  leaving  til;' 
duodenum  and  stomach  very  little  affected,  "although  lure 
was  no  doubt  the  primary  disease."  At  the  pylorus  was  an 
ulcer  about  the  size  of  a  shilling,  partly  in  the  duodenum  and 
partly  in  the  stomach.  It  had  raised  edges  composed  of  a 
cancerous  material,  but  these  wire  -nit  and  of  cheesy  consis- 
tence, shewing  the  cancer  breaking  up  and  degenerating.  The 
whole  thickness  of  the  wall  of  the  duodenum  and  stomach 
was  not  affected,  although  the  glands  and  omentum  were 
extremely  adherent,  and  there  was  much  puckering  of  the 
tissues.     Then-  were  secondary  deposits  in  the  liver. 

II.  A  woman,  aged  about  sixty,  was  admitted  under  Dr. 

Pavy  with  emaciation  and  jaundice.      The  clinical  account   is 

imt  preserved.      The  stomach  was  normal,  but  on  passing  the 


314  Duodenal  Ulcer 

finger  through  the  pylorus  considerable  constriction  was  felt 
beyond  it,  and  the  duodenum  appeared  to  be  puckered.  On 
slitting  it  open  the  first  part  of  the  duodenum  was  seen  to  be 
surrounded  by  a  tough,  firm,  fibrous  growth,  which  appeared 
for  the  most  part  outside  the  wall  of  the  intestine.  On  the 
posterior  wall  of  the  duodenum,  beyond  the  pylorus,  was  an 
ulcer  an  inch  in  diameter,  with  thickened  edges  and  floor,  the 
latter  consisting  of  tough  material  in  the  portal  fissure,  appar- 
ently new-growth,  though  the  edge  more  nearly  resembled  that 
of  a  simple  chronic  ulcer.  However,  the  ulcer  with  the  thick 
material  at  its  base  had  involved  the  gall-bladder  and  strangled 
it  so  completely  that  nothing  now  remained  of  it  save  a  small 
cavity  of  the  size  of  a  pea  containing  greenish  mucus.  The 
ductus  communis  choledochus  was  followed  to  its  termination, 
and  it  was  now  quite  patent,  a  probe  passing  easily  along  it, 
but  about  an  inch  from  the  papilla  its  walls  were  infiltrated 
for  half  an  inch,  and  at  this  part  the  tube  became  rather  con- 
tracted. Beyond  this  part  the  duct  was  dilated  so  as  to  admit 
the  little  finger  easily.  "I  think,"  says  Dr.  Goodhart,  "there 
could  be  no  doubt  that  before  the  parts  were  disturbed  there 
had  been  complete  obstruction  behind  the  growth.  The 
pancreatic  duct  was  not  dilated  and  the  portal  vein  was  free. 
It  seemed  to  be  a  case  of  a  new-growth  originating  in  the  floor 
of  a  chronic  ulcer,  and  spreading  thence  to  the  surrounding 
parts." 

At  a  meeting  of  the  Royal  Academy  of  Medicine  in 
Ireland  Dr.  Boxwell  exhibited  a  specimen  of  carcinoma 
following  an  ulcer  of  the  duodenum  ("Lancet,"  1907, 
ii.   1687): 

The  organs  were  obtained  from  a  man  of  sixty  who  had 
been  suffering  for  some  years  from  attacks  of  jaundice,  some- 
times with  slight  vomiting,  but  he  never  had  much  pain» 
At  the  necropsy  it  was  found  that  there  was  something  like 
an  ulcer  occupying  the  ampulla  of  Vater,  just  at  the  entry  of 
the  common  duct ;  carcinomatous  nodules  were  scattered 
through  the  lungs,  but  there  were  no  deposits  on  the  liver. 


The  Pathology  of  Chronic  Duodenal  Ulcer    315 

The  following  case  is  recorded  by  Ewald  ("Berl.  klin. 
Woch.,"  1886,  Xo.  32,  p.  527): 

Woman,  sixty-seven  years  of  age,  had  been  in  hospital  for 
some  time  with  an  old  fracture  of  the  thigh.  Began  to  have 
gastric  symptoms  in  the  spring  of  1885,  to  which  at  first  very 
little  attention  was  paid.  As  the  condition  did  not  improve 
under  the  ordinary  remedies,  a  test-breakfast  was  given  and 
the  stomach  contents  were  examined.  Lactic  acid  was 
present  but  no  hydrochloric  acid.  A  mixture  containing 
dilute  HC1  was  given  with  apparently  good  results.  After  a 
time  patient  began  to  have  severe  pain  in  the  epigastrium  and 
round  the  umbilicus.  Anorexia  and  rapid  wasting  led  to  the 
suspicion  of  carcinoma.  A  second  examination  of  the  stomach 
contents  still  showed  the  absence  of  free  HC1.  Patient 
gradually  became  weaker,  and  died  in  March,  1886. 

I 'o-t -mortem:  Instead  of  a  gastric  carcinoma,  which  was 
suspected,  there  was  found  a  duodenal  ulcer  which  had  under- 
gone carcinomatous  degeneration.  The  ulcer  was  situated 
2  cm.  from  the  pylorus  over  the  head  of  the  pancreas.  The 
margins  were  heaped  up  and  wall-like;  the  ulcer  was  circular, 
smooth,  1.8  cm.  in  diameter,  and  projected  through  the  serosa 
a--  a  nodular  growth  scarcely  as  big  as  a  cherry,  which  was 
firmly  adherent  to  the  margin  of  the  liver.  The  head  of  the 
pancreas,  though  in  close  relation  to  the  growth,  was  not 
invaded.  In  the  liver,  however,  the  tumour  tissue  had 
penetrated  a  good  way.  Xo  secondary  growths  elsewhere. 
Microscopic  examination  shewed  firm  connective  tissue,  and 
here  and  there  strands  of  epithelial  cells  and  accumulations  of 
round  cells.  The  condition  evidently  was  a  healed  round 
duodenal  ulcer,  in  the  scar  of  which  a  carcinoma  had  com- 
menced lo  develop.  Microscopic  examination  of  the  stomach 
wall  -hewed  a  partly  fibrous  and  partly  colloid  degeneration  of 
I  he  !iiiirou->  membrane  and  atrophy  of  the  glands. 

A  case  is  also  given  by  Eichhorsl  ("Zeitschr.  I.  klin. 
Med.,"  [888,  \i\,  519;  abstracts  in  "Schmidt's  Jahr- 
biicher,"  ccxx,  2 13,   [88 


3 16  Duodenal  Ulcer 

Man-servant,  forty-six  years  of  age.  Had  swelling  in 
neck  for  two  months,  night-sweats,  frequent  pains  in  tin- 
joints.  Legs  gradually  became  weak;  girdle  pains;  complete 
paraplegia  with  stoppage  of  urine  set  in  six  days  before  admis- 
sion. Present  condition:  Cachectic  man;  nodular  glandular 
enlargement  in  neck.  Complete  paralysis  and  anaesthesia  of 
the  lower  part  of  the  body,  with  disappearance  of  the  reflexes. 
Posteriorly,  anaesthesia  reaches  up  to  the  ninth  dorsal  vertebra. 
Death  after  six  days. 

Post-mortem:  Round  duodenal  ulcer  present,  with  car- 
cinomatous degeneration  of  the  margins.  Secondary  growth- 
in  the  liver,  lymphatic  glands,  vertebrae,  dura  mater,  and  also 
extending  into  the  spinal  cord  itself. 

The  following  case,  illustrating  the  development  of 
carcinoma  in  the  base  of  a  chronic  ulcer,  is  recorded  by 
Peck  ("Annals  of  Surgery,"  1910,  i,  952): 

About  two  years  ago  Dr.  Peck  said  he  operated  on  an  acute 
perforated  duodenal  ulcer  that  had  come  on  after  a  sudden 
strain  in  lifting.  There  was  no  induration  about  the  ulcer 
and  the  patient  made  a  good  recovery.  About  a  year  later 
there  was  a  second  acute  perforation,  apparent ly  at  the 
same  site,  but  this  time  the  inflammatory  changes  surrounding 
the  lesion  were  well  marked.  He  simply  closed  the  perfora- 
tion, without  doing  a  gastroenterostomy.  The  patient  re- 
covered from  that  operation,  but  did  not  do  well.  Then- 
were  symptoms  of  obstruction,  and  two  weeks  later  he  was 
forced  to  do  a  gastroenterostomy,  from  the  effects  of  which 
the  patient  died.  The  autopsy  shewed  a  more  extensive  and 
deeper  duodenal  ulcer,  with  a  very  small  carcinoma  which  must 
have  developed  in  the  interval  since  the  first  operation. 

I  have  on  a  few  occasions  found  prepyloric  cancer  of 
the  stomach  in  association  with  active  or  healed  ulcers 
of  the  duodenum. 


APPENDIX 


CONTAINING    A    DETAILED    STATEMENT    OF    ALL    CASES 

OPERATED  UPON  TO  THE  END  OF  1908;  WITH 

AN  ANALYSIS  AND  SUMMARY 

By  Harold  Collinson    M.S..  F.R.C.S. 

ASSISTANT     SURGEON',      LEEDS     GENERAL     INFIRMARY;     CLINICAL     LECTURER      IN      SURGERY, 
UNIVERSITY    OF    LEEDS,    ETC. 


The  patients  whose  ease  histories  are  appended 
number  187,  and  the  period  covered  is  nine  years  (1900- 
1908). 

Sex. — Males,  138,  or  73.7  per  cent.;  females,  49, 
or  26.2  per  cent. 

Variety  of  Ulcer. — Amongst  the  138  male  patients 
1  here  were  108  cases  in  which  duodenal  ulcer  alone  was 
found,  and  30  cases  in  which  both  gastric  and  duodenal 
ulcers  were-  present.  Of  the  49  female  patient-,  t,2  had 
duodenal  ulcer  alone,  17  both  gastric  and  duodenal  ulcers. 
The  proportion  of  males  to  females  amongst  the  cases 
presenting  duodenal  ulcer  only  was  therefore  more  than 
three  to  one.  In  the  first  40  cases  operated  upon,  evi- 
dence of  both  gastric  and  duodenal  ulceration  was 
found  in  24. 

Age.  The  distribution  o\  the  patients  in  the  various 
decennial  period-  is  as  follows: 

317 


3 18  Duodenal  Ulcer 

Ye  vrs 

( )rre  to  ten Xonc 

Eleven  to  twenty 3 

Twenty-one  to  thirty 37 

Thirty-one  to  forty 57 

Forty-one  to  fifty 45 

Fifty-one  to  sixty 2j 

Sixty-one  to  seventy 11 

Age  not  stated 7 

The  youngest  was  aged  seventeen  and  the  oldest  sixty- 
seven;  it  must  be  borne  in  mind,  however,  that  the  age 
given  is  that  of  the  patient  at  the  time  of  operation,  and 
not  at  the  onset  of  symptoms,  and  that  many  of  the 
patients  who  were  over  the  age  of  forty  had  had  symp- 
toms for  a  considerable  number  of  years.  The  longest 
duration  of  illness  before  operation  was  forty  years 
(Case  163)  and  the  shortest  seven  weeks  (Case  45);  in 
this  case  melaena  was  severe,  and  practically  the  only 
symptom. 

Symptoms. — In  examining  the  case  histories  one  is 
impressed  by  two  facts:  First,  that  in  the  earlier  cases 
the  clinical  picture  which  we  are  now  accustomed  to 
associate  with  the  presence  of  duodenal  ulcer  is  only 
imperfectly  indicated  in  the  account  of  the  patient's 
symptoms,  whilst  in  the  majority  of  the  later  cases  the 
patient's  account  of  his  symptoms,  given  after  careful 
enquiry,  is  typical.  The  second  point  of  interest  is  that 
in  the  early  cases  operation  was  in  a  large  proportion  of 
the  cases  undertaken  for  the  more  serious  complications 
of  duodenal  ulceration  rather  than  for  the  relief  of 
symptoms  due  to  the  ulcer  itself.  When  one  divides 
the  cases  into  those  occurring  during  the  first  half  of  the 
period,  i.  e.,  to  the  end  of  June,  1904,  and  those  between 


Detailed  Statement  of  Cases  Operated  Upon  3 19 

that  date  and  the  end  of  1908,  it  is  seen  that  during  the 
first  period  there  are  39  patient s  (Cases  3  and  40  refer- 
ring to  the  same  patients  as  Cases  2  and  24),  and  in  the 
second  there  are  148  (Cases  54  and  172  referring  to  one 
patient). 

Amongst  the  39  patients  operated  upon  up  to  the  mid- 
dle of  1904  are  9  (23  per  cent.)  in  whom  gastric  dilata- 
tion is  described  as  being  great,  and  in  some  instances 
enormous,  and  7  patients  (18  per  cent.)  in  whom  haemor- 
rhage was  very  severe.  Amongst  the  148  patients 
operated  upon  during  the  second  period,  15  only  (10 
per  cent.)  presented  dilatation  which  was  described  as 
severe  and  11  (7.4  per  cent.)  haemorrhage  which  was 
alarming. 

The  details  of  the  cases  mark  the  gradual  increase  of 
our  knowledge  of  duodenal  ulcer;  in  the  earlier  period 
symptoms  were  little  understood,  accurate  information 
as  to  the  time  of  onset  of  pain  was  not  sought,  and  it 
was  only  the  grosser  and  more  serious  results  of  ulcer- 
ation which  brought  the  patient  into  the  hands  of  the 
surgeon;  as  our  knowledge  of,  and  familiarity  with,  the 
condition  have  increased,  so  the  cases  have  been  seen 
earlier,  their  symptoms  more  carefully  investigated, 
and  operation  advised  and  performed  in  most  cases 
before  the  onset  of  dangerous  ((implications. 

Hemorrhage. — Seventy-one  patients  !,vs  per  cent.) 
gave  a  history  of  bleeding  at  one  time  or  another;  of 
these,  17  had  haematemesis  alone.  24  had  melaena  alone. 
30  had  both  haematemesis  and  melaena. 

Amongst  the  140  cases  in  which  duodenal  ulcer  alone 
was   found,   haemorrhage   was  noted  in   50  cases     55.7 


320  Duodenal  Ulcer 

per  cent.):  9  had  haematemesis  alone  (6.4  per  cent.); 
19  had  melaena  alone  (13.5  percent.);  22  had  haematem- 
esis  and  melaena  (15.8  per  cent.). 

In  the  47  cases  in  which  there  was  evidence  of  both 
gastric  and  duodenal  ulcers  haemorrhage  was  appar- 
ently mainly  due  to  the  duodenal  ulceration  in  7  cases 
(Cases  5,  15,  16,  19,  20,  97,  182);  4  of  these  had  melaena 
only,  and  3  both  haematemesis  and  melaena. 

In  18  cases  haemorrhage  was  severe,  and  in  most  of 
these  was  the  chief  symptom  for  which  the  patient 
sought  operative  treatment  (Cases  7,  14,  19,  20,  2"j,  28, 
41,  43.  45,  46,  72,  86,  95,  114,  138,  152,  153,  181).  In 
12  of  these  duodenal  ulcer  alone  was  present,  and  in 
Case  19,  although  there  was  evidence  of  gastric  ulcer- 
ation, it  was  the  duodenal  ulcer  which  was  bleeding. 
If  we  add  this  case  to  the  140  cases  in  which  duodenal 
ulcer  alone  was  found,  the  percentage  of  cases  in  which 
haemorrhage  was  really  severe  amounts  to  9.2  per  cent. 

Stenosis. — Although  in  a  large  number  of  the  cases 
gastric  dilatation  is  described  as  being  present,  this  was 
not  always  accompanied  by  definite  stenosis  of  the  duo- 
denum; in  43  instances,  however,  the  lumen  of  the 
duodenum  was  noticed  to  be  narrowed  by  the  contrac- 
tion of  an  ulcer. 

Perforation  of  Ulcer. — Amongst  the  140  cases  in  which 
duodenal  ulcer  was  found  alone  there  were  evidences  of 
old  perforation  in  5  (3.6  per  cent.).  Case  17:  Operated 
upon  eight  months  previously  for  perforation.  Cases 
38  and  177:  In  these  a  subacute  perforation  occurred  a 
short  time  before.  Cases  169  and  178:  An  ulcer  had 
probably  perforated  a  considerable  time  previous  to  the 
operation. 


Detailed  Statement  of  Cases  Opera tecHJpon  321 

In  addition  to  the  above  cases,  a  perforation  had 
probably  occurred  some  time  before  in  Case  98,  but  it 
is  uncertain  whether  it  was  of  a  gastric  or  duodenal 
ulcer.  Case  147  shewed  an  old  perforation  of  a  gastric 
ulcer. 

Tetany. — Three  cases  (Cases  6,  10,  58)  gave  a  history 
of  tetany.  In  all  of  these  both  gastric  and  duodenal 
ulcers  were  present  and  the  stomach  was  much  dilated. 

Cardiospasm.. — In  three  cases  (Cases  161,  168,  194) 
spasm  of  the  cardiac  opening  of  the  stomach  was  present, 
and  in  Case  161  this  was  apparently  the  chief  trouble. 

Operative  Treatment. — Upon  the  187  patients  195 
operations  were  performed. 

Eight  patients  were  operated  upon  twice,  viz.: 

Cases  2  (see  Case  3),  24  (see  Case  40),  54  (see  Case 
172),  80,  83,  99,  100,  173. 

The  195  operations  may  be  classified  as  follows: 

Posterior  gastro-enterostomy  by  simple  suture 79 

Posterior  gastro-enterostomy  by  simple  suture  with  infolding 

of  ulcer 84 

Posterior  gastro-enterostomy  (with  Laplace's  forceps),  cases  1 

and  2 2 

Posterior  gastro-enterostomy  (with  Murphy's  button),  case  3  1 
Posterior  gastro-enterostomy  (Mayo's  method),  casts  74,  84, 

106,  152 4 

Posterior  gastro-enterostomy  and  gastroplasty  (case  to8).  .  .  1 
Anterior  gastro-enterostomy  with  lateral  anastomosis  (ca 

159) 1 

Modified  Roux's  operation  (cases  17,  169) ..  .  2 

Division  of  loop  and  lateral  implantation  (case  1 1 

Lateral  anastomosis  between  limbs  of  loop  (case  40; .  .  1 

Posterior  gastro-enterostomy  with  cholecystotomy  (cases  12, 

78,  83,  i;,n: 4 

Posterior  gastro-enterostomy   with  cholecystectomy    (cases 

[6l    [63) 2 

Posterior  gastro-enterostomy  with  appendicectomj  (cases  75, 

176   1V>  ...       3 

21 


322  Duodenal  Ulcer 

Posterior  gastroenterostomy  with  radical  cure  of  hernia  (case 

46) 

Posterior  gastro-enterostomy  with  excision  of  duodenal  ulcer 

(cases  114,  182) 

Excision  of  duodenal  ulcer  alone  (case  183) 

Excision  of  gastric  ulcer  (case  173) 

Closure  of  pylorus  (case  172) 

Cholecystenterostomy  (case  180) 

Cholecystectomy  (case  80) 

Exploratory  laparotomy  (case  83 ) 

Excision  of  perforated  jejunal  ulcer  with  fresh  anastomosis 

(case  99) 1 

Total 195 

In  Cases  I  and  2  gastro-enterostomy  was  performed 
with  the  aid  of  Laplace's  forceps,  with  strikingly  differ- 
ent results.  The  former  of  the  two  patients  is  now  well 
and  free  from  trouble.  The  second  returned  two  months 
later  with  a  recurrence  of  symptoms ;  when  the  abdomen 
was  opened  (Case  3),  the  stoma  was  found  to  be  almost 
closed,  and  a  fresh  anastomosis  was  performed  with 
Murphy's  button;  the  patient  is  now  quite  well.  These 
three  operations  are  the  only  ones  in  which  any  appli- 
ance was  used  in  the  performance  of  the  anastomosis. 

In  four  cases  posterior  gastro-enterostomy  was  per- 
formed by  the  antiperistaltic  method;  the  number  is 
too  small  to  allow  one  to  draw  any  conclusions  as  to  the 
relative  advantages  of  this  method;  one  of  the  four 
patients  has  been  troubled  with  regurgitant  vomiting 
since  the  operation. 

The  other  cases  which  were  twice  operated  upon  are 
of  considerable  interest. 

Case  24  (see  also  Case  40) :  A  posterior  gastro-enter- 
ostomy was  performed  by  simple  suture;  one  week 
later  severe  vomiting  commenced,  and  lasted  with  short 


Detailed  Statement  of  Cases  Operated  Upon   323 

intermissions  for  a  year,  when  the  abdomen  was  reopened. 
It  was  then  found  that  the  whole  of  the  small  intestine, 
with  the  exception  of  the  last  18  inches,  had  passed  into 
the  lesser  peritoneal  sac  through  the  opening  made  in 
the  transverse  mesocolon.  The  herniated  bowel  was 
reduced  and  a  rather  long  loop  was  found  to  have  been 
left  between  the  flexure  and  the  stoma;  a  lateral  anasto- 
mosis was  performed  between  the  limbs  of  the  loop,  and 
the  margins  of  the  opening  in  the  mesocolon  were 
sutured  to  the  line  of  the  gastroenterostomy  opening. 
A  similar  accident  produced  a  fatal  result  in  Case  16. 

Case  54:  In  this  case  there  was  no  stenosis  and  the 
duodenum  was  not  infolded  at  the  time  of  the  gastro- 
enterostomy; for  a  time  the  operation  conferred  some 
benefit,  but  the  patient  returned  three  years  later  (see 
Case  172)  with  a  recurrence  of  all  symptoms,  pain  two 
to  three  hours  after  food,  relieved  by  food  or  bicarbonate 
of  soda,  and  frequent  vomiting.  The  abdomen  was 
reopened  and  the  following  condition  found:  The  anas- 
tomosis shewed  a  slightly  longer  loop  than  would  be  left 
at  the  present  time,  and  the  stoma  would  admit  three 
finger  easily.  The  pylorus  was  patent,  and  at  the  site 
of  the  ulcer  found  at  the  previous  operation,  of  which 
a  drawing  had  been  kepi  in  the  old  notes,  a  lar.ue  scar 
was  present;  close  to  this  were  two  other  well-marked 
ulcer-,  evidently  of  recent  date.  The  explanation  seems 
in  be  that  pylorospasm  was  formerly  presenl  along  with 
the  duodenal  uIc.t;  the  gastroenterostomy  acted  at 
first,  but  a-  the  spasm  relaxed  the  opening  ceased  to  be 
functional  and  ulceration  recurred.  The  pylorus  was 
closed    by    sutures    infolding    the    ulcerated    area,    and 


324  Duodenal  Ulcer 

although  it  is  not  long  since  the  second  operation  was 
performed,  the  patient  is  quite  free  from  trouble. 

Case  80:  At  the  time  of  the  first  operation,  which  was 
a  gastro-enterostomy  for  duodenal  ulcer,  a  calculus  was 
felt  in  the  pelvis  of  the  gall-bladder;  but  owing  to  the 
feeble  condition  of  the  patient,  it  was  thought  wiser  not 
to  prolong  the  operation.  During  convalescence  an 
acute  attack  of  epigastric  pain  occurred,  and  similar 
attacks  recurred  at  intervals  for  the  next  two  years. 
These  attacks  came  on  soon  after  food,  and  were  more 
acute  than  the  pain  before  the  first  operation,  which  usu- 
ally came  three  hours  after  a  meal.  Their  character 
was  such  that  a  second  operation  was  decided  upon,  and 
the  gall-bladder  was  explored;  it  was  found  to  be  hour- 
glass in  shape  and  to  contain  several  calculi.  It  was 
removed.  The  scar  of  the  old  duodenal  ulcer  was  seen 
and  infolded;  there  was  no  evidence  of  fresh  ulceration. 
The  patient  has  done  well. 

Case  100:  In  this  case  a  recurrence  of  pain  and  flatu- 
lence, with  occasional  vomiting  and  some  loss  of  weight, 
raised  a  suspicion  of  a  possible  malignant  change  in  the 
ulcerated  area,  and  the  abdomen  was  reopened  sixteen 
months  after  the  first  operation.  There  was  no  evidence 
of  carcinoma  and  the  pylorus  was  freely  patent.  A 
slight  "loop"  was  present,  and  so  the  afferent  limb  was 
divided  and  anastomosed  with  the  efferent  by  an  end- 
to-side  implantation;  the  pylorus  was  narrowed  by 
suture.  There  has  been  slight  improvement  in  the 
symptoms  as  a  result. 

Case  173:  Gave  a  long  history  of  indigestion,  with  one 
attack  of  haematemesis  at  least.     Pain  varied  in  time 


Detailed  Statement  of  Cases  Operated  Upon  325 

of  onset,  sometimes  immediately,  but  generally  two 
hours  after  food.  Liquids  caused"  more  discomfort  than 
solids,  a  drink  of  water  producing  almost  immediate 
pain.  A  diagnosis  of  duodenal  ulcer  was  made,  but  at 
operation  no  lesion  could  be  detected  in  the  duodenum 
on  either  inspection  or  palpation.  On  the  lesser  curva- 
ture of  the  stomach,  however,  slightly  nearer  the  cardia 
than  the  pylorus,  was  a  large  ulcer  with  induration 
extending  into  both  anterior  and  posterior  walls.  This 
was  excised  and  the  incision  sutured.  Xo  gastroenter- 
ostomy was  performed.  Relief  followed  the  operation 
for  four  months,  and  then  pain  recurred,  coming  two  to 
three  hours  after  food  and  always  relieved  by  the  next 
meal.  There  was  no  vomiting.  The  weight  which  had 
been  regained  was  rapidly  lost.  Fourteen  months  after 
the  first  operation  the  abdomen  was  reopened ;  the  scar 
of  the  previous  excision  was  found  to  be  perfect ;  there 
was  no  narrowing  and  only  a  few  thin  adhesions.  The 
first  part  of  the  duodenum  was  surrounded  by  adhesions, 
and  a  large  indurated  ulcer  was  found  on  its  anterior 
aspect.  Posterior  gastroenterostomy  was  performed 
and  the  ulcer  infolded.  The  patient  has  been  perfectly 
well  since.  There  is  no  doubt  that  the  chief  symptoms 
before  the  first  operation  were  caused  by  the  gastric 
ulcer,  but  the  variable  thin  of  onset  of  pain  for  a  few 
months  before  operation  makes  it  probable  that  the 
duodenum  was  the  site  of  early  ulceration,  even  al  that 
time,  although  no  lesion  could  be  detected  on  exami- 
nation of  the  exterior  of  the  gut. 

In  three  cases  anterior  gastroenterostomy  had  to  be 
performed  in  place  of  the  posterior  operation  on  account 


326  Duodenal  Ulcer 

of  technical  difficulties;  in  two  of  these  (Cases  17  and 
[69)  the  loop  was  divided  and  the  afferent  limb  implanted 
into  the  efferent,  and  in  the  third  (Case  159)  a  lateral 
anastomosis  was  performed  between  the  limbs. 

In  six  cases  gall-stones  were  removed  simultaneously 
with  the  performance  of  gastroenterostomy.  In  case 
12  the  patient  had  suffered  from  repeated  attacks  of 
severe  colicky  pain  in  the  right  hypochondrium,  accom- 
panied by  vomiting  and  always  followed  by  profuse, 
tarry  stools,  but  no  jaundice.  In  cases  78,  130,  and  161 
gall-stones  were  not  suspected  before  operation.  Case 
83  was  operated  upon  for  the  relief  of  attacks  of  typical 
biliary  colic  and  the  gall-bladder  drained  after  the 
removal  of  a  number  of  calculi;  it  is  a  pity  that  the 
gall-bladder  was  not  extirpated,  for  the  patient  died 
less  than  three  years  after  from  carcinoma  beginning  in 
the  gall-bladder  and  spreading  to  the  liver.  In  Case 
j  63  gall-stones  were  apparently  the  chief  trouble,  and  a 
cholecysto-duodenal  fistula  existed.  Case  180  is  of  the 
greatest  clinical  interest;  the  history  of  the  case  and  the 
physical  examination  strongly  suggested  obstructive 
jaundice  due  to  carcinoma  of  the  head  of  the  pancreas, 
and  it  was  not  until  the  pathologist's  report  on  the  chem- 
ical examination  of  the  urine  and  faeces  demonstrated 
that  the  obstruction  involved  the  common  duct  above 
the  level  of  its  junction  with  the  pancreatic  that  oper- 
ation was  suggested;  an  indurated  scar  in  the  duodenal 
wall  was  found  to  be  compressing  the  common  bile-duct 
and  a  cholecyst-enterostomy  was  performed.  Unfortu- 
nately, the  junction  had  to  be  made  with  the  colon  on 
account   of   mechanical   difficulties,   and   no   doubt   the 


Detailed  Statement  of  Cases  Operated  Upon  327 

three  short  attacks  of  pain  and  pyrexia  with  jaundice 
which  the  patient  has  experienced  since  operation  have 
been  due  to  cholecystitis  with  an  ascending  infection. 
With  this  exception  the  operation  appears  to  have 
brought  complete  relief. 

Cholecysto-duodenal  fistulae  were  found  in  two  cases 
Nos.  81  and  163);  in  the  former,  due  to  duodenal 
ulceration;   in  the  latter,  probably  due  to  gall-stones. 

In  Case  108  an  hour-glass  contraction  of  the  stomach 
was  present, '  necessitating  the  performance  of  gastro- 
plasty at  the  same  time  as  gastro-enterostomy. 

Excision  of  a  duodenal  ulcer  without  gastro-enteros- 
tomy was  the  operation  in  Case  183;  scarcely  a  year 
has  elapsed  since  the  operation,  'but  a  quite  recent 
report  states  that  the  patient  is  very  well. 

Operative  Results. — Four  patients  out  of  the  186 
died  as  the  result  of  the  operation  (2.15  per  cent.): 
Case  16 — acute  intestinal  obstruction,  on  the  tenth  day; 
Case  33 — uraemia,  on  the  third  day;  Case  99 — perfor- 
ation of  jejunal  ulcer,  on  thirteenth  day;  Case  112 — 
acute  tuberculosis,  on  fourteenth  day. 

The  details  of  the  cases  are  as  follows: 

Case  16:  Death  occurred  on  the  tenth  day  with  symp- 
toms pointing  to  intestinal  obstruction.  At  the  autopsy 
it  was  found  that  almost  the  whole  of  the  small  intestine 
had  passed  into  the  lesser  sac  through  the  opening  made 
in  the  transverse  mesocolon  for  the  performance  of  the 
anastomosis.  A  similar  hernia  occurred  in  Case  24; 
this  was  more  gradual  in  onset,  bu1  necessitated  opera- 
tion at  a  later  date  since  that  time  it  has  been  a 
routine  procedure  to  suture  the  margins  of  the  opening 


328  Duodenal  Ulcer 

in  the  mesocolon  to  the  line  of  the  anastomosis  in  order 
to  prevent  such  an  accident. 

Case  33:  This  patient  was  admitted  with  a  ten-year 
history  of  pain  after  food  and  vomiting;  albumen  was 
noted  in  the  urine  before  operation,  but  there  is  no  note 
as  to  whether  casts  were  found.  At  the  operation  there 
were  no  external  evidences  of  ulceration  in  the  duodenum, 
but  gastro-enterostomy  was  performed.  The  patient 
died  three  days  after  with  symptoms  of  uraemia.  At 
autopsy  the  kidneys  were  found  to  be  small  and  granular, 
with  much  narrowing  of  the  cortex.  In  the  duodenum 
there  was  ulceration  without  induration,  probably 
uraemic  in  origin. 

Case  99:  In  this  case  posterior  gastro-enterostomy 
was  performed  for  a  duodenal  ulcer  which  was  infolded. 
Until  the  thirteenth  day  the  patient  did  very  well,  and 
was  then  allowed  to  get  up.  Almost  immediately  after 
getting  out  of  bed  he  complained  of  acute  abdominal 
pain  and  vomited.  Next  day  he  seemed  rather  better, 
but  vomited  in  the  evening,  and  the  following  day — the 
fifth  after  operation — was  very  ill  and  the  abdomen  was 
reopened.  No  free  fluid  was  found  in  the  peritoneal 
cavity,  but  the  eoils  of  small  intestine  were  slightly 
injected.  It  was  difficult  to  expose  the  anastomosis  on 
account  of  adhesions,  and  as  these  were  separated,  a 
perforation  of  the  jejunum  just  distal  to  the  anastomosis 
was  found.  In  order  to  close  this,  the  anastomosis  had 
to  be  disconnected.  This  was  done,  the  ulcer  excised, 
the  opening  in  the  stomach  closed,  and  a  fresh  anasto- 
mosis performed  away  from  the  first  position.  The 
patient  died  shortly  afterwards. 


Detailed  Statement  of  Cases  Operated  Upon  329 

Case  112:  This  patient  had  a  duodenal  ulcer,  and  in 
addition  several  tuberculous  deposits  at  the  ileocecal 
junction  and  in  the  large  intestine.  He  died  fourteen 
days  later  with  symptoms  of  acute  tuberculosis. 

Four  other  patients  are  since  dead  at  varying  periods 
after  the  operation. 

Case  30:  Four  years  later,  from  cardiac  disease; 
apparently  no  recurrence  of  stomach  symptoms. 

Case  38:  At  operation  a  subacute  perforation  of  a 
large  duodenal  ulcer  was  found.  For  the  first  ten 
months  after  operation  was  entirely  free  from  trouble 
and  gained  weight;  then  pain  began  to  recur,  at  first  at 
long  intervals,  but  gradually  becoming  more  frequent 
and  severe,  with  occasional  vomiting.  Two  and  one- 
half  years  after  operation  she  began  to  lose  weight 
rapidly,  and  ascites  and  marked  anaemia  developed,  with 
inability  to  retain  food.  Death  ensued  from  asthenia 
and  exhaustion  three  years  and  four  months  after  oper- 
ation. The  cause  of  death  was  probably  carcinoma, 
but  whether  of  duodenum  or  stomach  it  is  impossible 
to  say,  as  no  autopsy  was  obtained. 

Case  55:  In  this  case  a  suspicion  of  carcinoma  was 
raised  before  operation,  as  the  stomach  contents  were 
only  faintly  acid,  contained  no  free  HC1,  and  lactic 
acid  was  present.  At  the  operation,  however,  no  evi- 
dence of  carcinoma  could  be  detected,  and  the  -ear  of 
an  ulcer  was  present  in  the  duodenum.  The  patient's 
doctor  reports  that  he  died  two  years  later  from  "per- 
nicious anaemia,"  the  symptoms  of  which  had  appeared 
only  four  months  before.  There  were  apparently  no 
symptoms  pointing  to  gastric  carcinoma. 


330  Duodenal  Ulcer 

Case  83:  Operation  in  this  case  was  undertaken  for 
the  relief  of  symptoms  of  cholelithiasis,  and  the  gall- 
bladder, which  contained  many  small  calculi,  was  evac- 
uated and  drained.  The  contracted  scar  of  a  duodenal 
ulcer  was  present,  so  gastro-enterostomy  was  performed. 
Two  years  and  nine  months  later  he  was  readmitted  to 
the  Nursing  Home  with  a  large  tumour  in  the  region  of 
the  gall-bladder.  An  exploratory  operation  revealed 
extensive  carcinoma  involving  the  gall-bladder  and 
infiltrating  the  liver.  The  abdomen  was  closed  and  he 
died  some  weeks  later. 

In  the  remaining  178  cases  an  attempt  has  been  made 
to  obtain  a  report  of  the  present  condition  of  the  patient 
by  writing  to  the  doctor  who  sent  the  case,  and  in  some 
instances  to  the  patients  themselves.  In  a  few  cases  the 
patients  have  been  seen  personally  within  the  last  few 
months.  Reports  are  attached  to  the  case  histories, 
and  wherever  possible  are  given  in  the  words  of  the 
patient  or  medical  man. 

In  11  cases  (Cases  4,  15,  32,  52,  73,  81,  98,  129,  140, 
165,  189)  attempts  to  trace  the  patients  have  been 
unsuccessful,  and  no  report  is  available  at  a  longer 
period  after  the  operation  than  a  few  months. 

In  4  cases  (Cases  7,  14,  42,  43)  a  report  was  obtained 
in  1905,  but  none  has  been  available  since  that  time. 
In  cases  7  and  14  this  report  was  three  and  one-half 
and  two  and  three-quarter  years  after  operation  respec- 
tively, and  they  may  be  classed  as  cures;  Case  42  was 
improved,  and  Case  43,  although  the  report  was  only 
twelve  months  after  operation,  appeared  to  be  cured. 
Of  the  163  patients  concerning  whom  recent  reports  have 


Detailed  Statement  of  Cases  Operated  Upon  331 

been  obtained,  144  may  be  classed  as  cured.  The 
remaining  19  cases  are  not  yet  entirely  free  from  trouble, 
and  details  of  them  are  appended. 

Case  17:  A  case  of  gastroenterostomy  nine  months 
after  operation  for  perforation  of  a  duodenal  ulcer.  An 
anterior  operation  by  Roux's  method  had  to  be  per- 
formed, owing  to  the  almost  universal  adhesions.  Pa- 
tient has  now  occasional  epigastric  pain,  probably  due 
to  adhesions,  but  is  otherwise  in  excellent  health.  Very 
much  improved. 

Case  18:  A  very  good  report  in  1905  (three  and  one- 
half  years  after  operation).  Last  report  not  quite  so 
favourable;  has  occasional  bilious  vomiting,  but  is  evi- 
dently much  improved. 

Case  23:  The  patient  still  suffers  from  distension  and 
flatulence,  but  is  distinctly  better  for  the  operation. 

Case  24  (see  also  Case  40) :  This  patient  suffered  from 
severe  vomiting,  which  began  one  week  after  posterior 
gastroenterostomy  and  lasted,  with  short  intermissions, 
until  one  year  later,  when  the  abdomen  was  reopened. 
It  was  then  found  that  almost  all  the  small  intestine  had 
herniated  through  the  opening  in  the  transverse  mes<  >- 
colon.  This  was  reduced  and  a  lateral  anastomosis 
between  limbs  of  loop  performed.  Patient  is  much 
better,  bu1  still  has  occasional  pain  and  vomiting.  The 
diagnosis  of  a  medical  man  who  saw  him  was  "ergophb- 
bia." 

e  36:    Eighteen  months  after  operation  reported  to 

be    little    better.       Recent    reporl    no1    \  er\     reliable,    but 

appears  to  be  bel  ter  than  he  was. 

Case  4;r  Suffers  from  attacks  of  regurgitant  vomit- 
ing, but  says  she  is  much  bel  ter. 


332  Duodenal  Ulcer 

Case  70:  Occasionally  vomits,  but  is  otherwise  very 
well. 

Case  74:  Still  has  attacks  of  regurgitant  vomiting 
every  three  or  four  weeks,  which  he  relieves  by  lavage, 
but  is  at  work  and  otherwise  well. 

Case  75:  Occasional  pain  and  vomiting,  but  is  much 
improved.     A  "neurotic." 

Case  76:  Still  suffers  from  flatulence  and  anaemia, 
but  is  much  improved. 

Case  88:  Occasional  pain  and  "water  brash,"  but 
much  better. 

Case  91:  Regurgitant  vomiting  of  bile  about  once  a 
week,  causing  no  pain.     Otherwise  quite  well. 

Case  100:  Much  relieved  for  one  year,  then  recurrence 
of  pain  and  distension  with  occasional  vomiting.  Fif- 
teen months  after  gastro-enterostomy  abdomen  opened, 
as  carcinoma  was  suspected;  none  found.  As  a  "loop" 
existed,  lateral  anastomosis  was  performed.  Recent 
report  (one  year  after  second  operation)  states  that  a 
ventral  hernia  has  developed ;    he  is  better  but  not  well. 

Case  104:    Much  improved;    practically  cured. 

Case  113:  Says  he  is  no  better,  although  doctor  thinks 
he  is.      Is  a  hypochondriac. 

Case  125:  Still  some  pain,  but  has  gained  11  lbs.  in 
weight,  and  is,  on  the  whole,  better. 

Case  161:  Patient  suffers  from  cardiospasm  and  is 
still  under  treatment. 

Case  176:  Not. much  improvement  six  months  after 
operation.  Patient  is  a  busy  practitioner  and  is  apt  to 
overwork,  but  when  seen  recently  was  very  much  better. 

Case  179:   Slow  improvement  taking  place  six  months 


Detailed  Statement  of  Cases  Operated  Upon  333 

after  operation;  one  year  after  operation  much  better 
and  back  at  work. 

Of  Case  113  one  is  bound  to  say  that  the  patient 
appears  to  be  no  better,  and  in  Case  161  improvement 
is  doubtful;  the  other  17  cases  are  distinctly  benefited, 
if  not  cured. 

Summarising,  therefore,  the  results  of  my  enquiries, 
we  have  the  following  result: 

164  recent  reports: 

Cured 145 

Improved 17 

Doubtful  improvement I 

Xo  better I 

4  reports  in  1905:  , 

Cured 3 

Improved I 

Cases  not  traced 11 

The  operative  results  work  out  as  follows: 

Died  as  result  of  operation 4  =  2.14'  , 

Died  at  varying  periods  of  other  causes  than  operation.  ...  4  =  2.14% 

Cured 148  =  79.14°; 

Improved 18  =  9.6  % 

Doubtful  improvement 1  =.    0.5   ' , 

No  better 1  =  0.5 

Not  traced 11=  5.9  % 

Cases  in  Which  Post-operative  Vomiting  Occurred. — 
In  the  following  12  cases  vomiting  occurred  for  a  vari- 
able length  of  time  after  operation  or  is  still  present. 

Case    6:    Now  cured. 

Case  [8:    Occasional  bilious  vomiting  still  present. 

Case  24:  (See  also  Case  40.)  Severe  vomiting  due  to 
hernia  into  lesser  sac,  much  relieved. 

Case  27:   Temporal")  regurgitation.     Now  cured. 
'    34:    Temporary  regurgitation.      Now  cured. 


334  Duodenal  Ulcer 

Case  42 :  Occasional  vomiting  one  year  after  operation. 
No  later  report. 

Case  49:    Regurgitant  vomiting,  still  persists. 

Case  70:    Still  vomits  occasionally. 

Case  74:  A  typical  attack  of  regurgitant  vomiting 
every  three  or  four  weeks. 

Case  91:    Regurgitant  vomiting,  still  persists. 

Case  100:  Occasional  vomiting.  Reoperated  with 
some  relief. 

Case  104:    Occasional  bilious  vomiting. 

Of  these  cases  of  post-operative  vomiting,  only  six 
(Cases  24,  27,  34,  49,  74,  91)  can  be  classed  as  true 
regurgitant  vomiting.  In  Case  24  the  vomiting  was 
severe  and  the  cause  removed  at  a  second  operation. 
In  Cases  27  and  34  the  vomiting  was  temporary  and  the 
cause  is  not  known,  unless  it  be  that  a  loop  was  left 
between  the  anastomosis  and  the  flexure.  In  Cases  49 
and  91  the  stomach  was  found  to  be  very  much  dilated, 
and  there  may  be  some  mechanical  difficulty  which  still 
causes. the  vomiting  to  persist.  In  Case  74  the  operation 
was  performed  by  the  antiperistaltic  method,  which  is 
now  not  used. 

In  arranging  the  case  histories  the  original  description 
of  the  operation  has  been  retained  with  the  exception  of 
occasional  slight  alterations  in  the  wording,  and  although 
in  some  of  the  earlier  cases  the  evidence  of  gastric 
ulceration  apparently  was  based  on  slighter  grounds 
than  would  now  be  accepted,  it  was  thought  inadvisable 
to  alter  the  nomenclature  in  any  way  at  this  date.  The 
reports  on  the  patients'  present  condition  have  been 
entered  in  the  form  received. 


Detailed  Statement  of  Cases  Operated  Upon  335 


COMPLETE  LIST  OF  CASES  OF  CHRONIC  DUODENAL  ULCER 

TREATED  BY  OPERATION 
D.  indicates  Duodenal  Ulcer;  G.  &  D.  indicate  Gastric  and  Duodenal. 

Case  i. — G.  &  D.  January,  1900.  Female,  aged  thirty- 
one.  At  the  age  of  sixteen  an  illness,  attended  with  heemat- 
emesis  on  one  occasion  in  large  quantity.  Pain  after  food 
ever  since,  varying  in  severity.  Diet  has  been  carefully 
regulated.  June,  1899,  pain  became  more  acute,  and  vomit- 
ing, which  before  had  been  inconstant,  now  became  frequent. 
Large  quantities  (4  pints)  were  vomited.  On  examination  a 
large  contracting  stomach  was  seen;    no  tumour  palpable. 

Operation:  Much  thickening  at  pylorus  and  along  first 
portion  of  duodenum,  with  stenosis  and  many  adhesions. 
The  adhesions  were  carefully  separated  and  posterior  gastro- 
enterostomy performed  with  the  aid  of  Laplace's  forceps. 
Recovery. 

Seen  July  29,  1902.  "Quite  well,  in  first-rate  health." 
March,  1905,  was  perfectly  well,  could  eat  all  foods,  and  had 
gained  11  lbs.  in  weight.  Seen  again  March,  1907.  Condi- 
tion still  quite  satisfactory. 

CASE  2. — G.  &  D.  January,  1900.  Male,  aged  fifty -five. 
Dyspepsia  for  ten  or  twelve  years,  culminating  five  years 
ago  in  a  severe  attack  which  lasted  two  weeks,  and  was 
remarkable  for  the  severity  and  continuance  of  epigastric  pain 
and  the  persistence  of  vomiting.  Since  that  time  has  had 
periodic  seizures  of  copious  vomiting  at  intervals  of  twenty- 
four  hours  to  three  weeks.  Pain  occurring  three  to  >i\  hours 
alter  food,  varying  greatly  in  severity,  but  generally  not 
amounting  to  more  than  discomfort.  On  one  occasion  in 
hospital  the  vomitus  measured  5 '  _>  pints.  Stomach  huge 
and  flabby,  greater  curvature  descending  behind  the  symphy- 
sis pubis.     Visible  peristalsis.     HCI  proem. 

Operation:  An  enormous  stomach;  an  ulcer  extending 
from  pylorus  into  first  part  of  duodenum.  Marked  cicatricial 
stenosis  adhesion  to  liver.  Posterior  gastroenterostomy 
with  Laplace's  forceps;  separation  of  old  adhesions.  Recov- 
ery. J'.ti  it  11 1  was  senl  by  Dr.  Bailey,  Horsforth.  (For 
further  details  sei   I 


336  Duodenal  Ulcer 

Case  3. — March,  1900.  Male,  aged  fifty-five.  (See  Case 
2.)  After  operation  in  January,  1900,  there  was  considerable 
relief  for  about  one  month.  Then  after  a  heavy  meal  con- 
sisting largely  of  boiled  peas  there  was  an  attack  of  pain  and 
vomiting,  and  from  that  date  his  previous  symptoms  (dys- 
pepsia, pain,  and  vomiting)  gradually  returned.  On  admis- 
sion  his  condition  was  practically  the  same  as  before  operation. 

Operation:  The  anastomosis  made  at  the  first  operation, 
between  the  stomach  and  intestine,  was  practically  closed. 
A  second  gastroenterostomy  with  the  aid  of  Murphy's  button 
was  performed.     Recovery. 

Seen  September,  1900.  Said  he  was  never  better  in  his 
lite;  had  gained  over  two  stone  in  weight  and  had  no  gastric 
discomfort.  Dr.  Bailey  writes,  April  3,  1908:  "Patient  very 
well  indeed;  has  gained  weight;  no  recurrence  of  pain  nor 
vomiting.  Has  not  required  any  medical  assistance  since 
operation." 

Case  4. — G.  &  D.  February  16,  1901.  Female,  aged 
fifty-one.  For  some  years  has  had  pain  after  food  and 
diarrhoea.  For  last  five  or  six  months  pain  has  been  much 
more  severe  and  has  followed  every  meal.  It  occurs  half  an 
hour  after  food,  and  lasts  for  three  hours  or  more.  Vomiting 
infrequent,  unless  self-induced  to  obtain  ease.  On  two 
occasions  has  noticed  blood,  but  only  in  small  quantities. 
Has  lost  weight  and  strength.  Continuous  medical  treat- 
ment for  five  months  has  proved  unavailing.  Stomach  a 
little  dilated;  tenderness  on  pressure  over  pyloric  region; 
excess  of  HC1. 

Operation:  Three  ulcers  were  found,  two  in  stomach  near 
lesser  curvature,  1  inch  and  2x/i  inches  respectively  from  the 
pylorus;  a  third  in  the  first  part  of  the  duodenum,  with  con- 
siderable induration.  Posterior  gastro-enterostomy  by  simple 
suture.  Recovery.  Patient  was  sent  by  Dr.  Lockwood, 
Halifax.  When  seen  three  months  after  the  operation,  had 
gained  10  lbs.  in  weight.     Cannot  be  traced  since. 

Case  5. — G.  &  D.  March  19,1901.  Mr.  P.,  aged  thirty. 
Symptoms  for  five  or  six  years.  Pain  in  epigastrium  after 
meals,  most  severe  during  the  night.  Slight  pain  between 
shoulders.     Vomiting  of  sour,  watery  phlegm  almost  every 


Detailed  Statement  of  Cases  Operated  Upon  337 

other  day  for  twelve  months.  On  one  occasion  blood.  Lost 
nearly  a  stone  in  weight;  attacks  of  faintness,  prostration, 
and  melaena. 

Operation:  An  ulcer  in  the  first  part  of  the  duodenum  with 
many  adhesions.  Small  scar  of  ulcer  on  posterior  surface  of 
stomach.  Posterior  gastroenterostomy.  Recovery.  Patient 
was  seen  with  Drs.  Millhouse  and  Anning. 

Dr.  Anning  writes,  February,  1908:  "Is  perfectly  well; 
has  gained  6  lbs.  in  weight.  There  has  been  no  recurrence  of 
pain,  vomiting,  nor  melaena.  Is  of  good  complexion,  whereas 
previously  he  was  always  anaemic." 

Case  6. — G.  &  D.  November  2,  1901.  T.  T.,  male,  aged 
forty.  Symptoms  began  in  June,  1900.  Burning  pain  and 
vomiting  after  food,  generally  half  an  hour  after  the  meal. 
Two  months  ago  a  severe  attack  of  vomiting,  lasting  two 
days.  Extreme  irritability  of  stomach.  No  haematemesis, 
no  melaena.  Has  had  severe  muscular  cramps  in  neck  and 
extremities  (tetany).  On  examination  a  huge,  contracting 
stomach,  loud  gurglings  in  pyloric  region,  free  HC1. 

Operation:  An  enormous  stomach  shewing  five  well-marked 
ulcers;  another  ulcer  in  duodenum  just  beyond  pylorus. 
Posterior  gastro-enterostomy.  Recovery.  Seen  with  Dr. 
Millhouse  and  Dr.  G.  P.  Anning,  Kirkstall. 

In  April,  1902,  had  gained  11  lbs.  Dr.  Anning  writes, 
February  7,  1908:  "Patient  in  very  good  health;  feels  better 
than  he  has  been  for  the  last  eight  years;  gain  in  weight  6 
lbs.  Xo  vomiting  for  two  years;  until  two  years  ago  he  had 
attacks  of  bilious  vomiting  at  long  intervals,  accompanied  by 
flatulence  lasting  a  day  or  two." 

Case  7. — G.  &  D.  January,  1902.  N.  G.,  female,  aged 
twenty-six.  For  the  last  few  months  pain  coming  on  immedi- 
ately after  food  and  lasting  for  three  or  four  hours.  Has 
therefore  limited  her  diet  and  has  lost  weight.  Four  weeks 
ago  had  haematemesis  and  melaena.  The  melaena  has  con- 
tinued ever  since  and  is  now  threatening  to  end  disastrously. 
II. 1-  fainted  in  bed  several  time-.  Very  anaemic;  pulse  96. 
Mi-  become  much   thinner  during  the  last   four  weeks. 

Operation:  An  elongated  and  thickened  nicer  in  the  duo- 
denum feeling  like  .1  date;  .1  second  ulcer  on  the  posterior 
22 


338  Duodenal  Ulcer 

wall  of  the  stomach.  Many  adhesions.  Posterior  gastro- 
enterostomy.    Patient  was  sent  by  Dr.  Ellis,  Halifax. 

In  September,  1902,  reported  to  be  in  perfect  health;  had 
regained  her  lost  weight  and  7  lbs.  over.  Report  received 
from  Dr.  Ellis,  June  26,  1905:  "Never  better;  gained  weight; 
no  trouble  in  any  way."     This  case  has  not  been  traced  since. 

(  ase  8.— G.  &  D.  February  3,  1902.  R.,  male,  aged  forty- 
three.  Twenty  years  ago  began  to  suffer  from  pain  after 
food,  and  vomiting.  Ever  since  has  been  subject  to  a  recur- 
rence of  trouble  and  has  carefully  limited  his  diet.  Vomit- 
ing from  time  to  time  in  large  quantities;  motions  occasionally 
tarry.  Last  October  a  sharp  attack  of  hsematemesis  and 
melaena.  Stomach  now  very  dilated,  reaching  2  inches  below 
umbilicus.     Lost  I  stone  in  weight  in  last  four  months. 

Operation:  A  very  large  flaccid  stomach;  at  the  pylorus 
and  a  little  beyond  much  thickening,  forming  a  tumour  equal 
in  size  to  a  walnut.  On  anterior  surface  of  stomach  a  dis- 
tinct scar  about  3  inches  from  pylorus.  On  posterior  surface 
a  similar  scar  with  adhesions  to  transverse  mesocolon.  Pos- 
terior gastro-enterostomy.  Recovery.  Patient  sent  by  Dr. 
Ellis,  Halifax. 

In  August,  1902,  reported  to  be  in  good  health;  quite  free 
from  stomach  troubles;  gained  I  stone.  Dr.  Ellis  reports, 
February  26,  1908:  "Gained  considerably  in  weight,  no 
recurrence  of  pain  nor  vomiting.  Has  been  perfectly  well 
since  operation." 

Case  9. — G.  &  D.  June  12,  1902.  Miss  A.,  aged  thirty- 
seven.  About  ten  years  ago  began  to  suffer  from  pain  after 
food  and  vomiting.  Was  confined  to  bed  on  several  occasions. 
The  vomiting  was  "dreadful,"  but  no  blood  was  ever  observed. 
Continual  indigestion  for  seven  years;  at  the  end  of  that 
period  an  alarming  haemorrhage.  Was  in  hospital  for  five 
weeks.  Vomiting  and  pain  continued  intermittently  since, 
and  for  several  months  has  noticed  occasionally  that  stools 
were  "black  as  ink."     Operation  advised  a  year  ago. 

Operation:  A  very  large  stomach,  numerous  adhesions 
around  pylorus  and  duodenum,  especially  on  the  posterior 
surface.  Some  marked  local  thickening  of  the  head  of  the 
pancreas  (an  example  of  chronic  interstitial  pancreatitis  due 


Detailed  Statement  of  Cases  Operated  Upon  339 

to  gastric  and  duodenal  ulceration).  Posterior  gastroen- 
terostomy.    Recovery.     Patient  sent  by   Dr.  Ellis,    Halifax. 

By  August  she  had  gained  12^  lbs. ;  by  September,  4  addi- 
tional pounds.  On  October  15th,  two  stone  heavier  than  at 
time  of  operation.  February,  1903,  gained  6  lbs.  more. 
Dr.  Ellis  reports,  February  26,  1908:  "Patient  quite  well; 
gained  in  weight;    no  recurrence  of  pain  nor  vomiting." 

Case  10. — G.  &  D.  July  2,  1902.  G.,  male,  aged  forty- 
seven.  Indigestion  for  four  or  five  years,  gradually  increasing 
in  severity  up  till  the  present  time,  when  he  is  disabled  from 
work.  Pain  coming  on  about  one  and  one-half  hours  after 
meals,  increasing  in  severity  for  an  hour  unless  eased  by 
vomiting,  which  always  afforded  relief.  There  has  never 
been  haemorrhage.  Has  had  cramps  in  his  arms  and  hands, 
rarely  in  the  legs,  especially  during  the  last  two  months 
(tetany).  On  examination,  a  very  large  stomach,  descending 
1 Y2  inches  below  the  umbilicus  before  inflation.  A  few  con- 
tractions seen  on  inflation. 

Operation:  A  very  large  stomach;  a  large  scar  on  the 
posterior  surface  near  the  lesser  curvature,  about  2  inches 
from  pylorus.  A  second  scar,  beginning  at  the  second  portion 
of  the  duodenum.  Many  adhesions  around  pylorus.  Pos- 
terior gastro-enterostomy.  Recovery.  Patient  was  sent  by 
Dr.  McNab,  Armley.  Made  a  rapid  recovery,  and  within 
three  weeks  was  eating  ordinary  meals  with  great  relish. 
Report  received  from  Dr.  McNab  June  21,  1905:  "The  results 
have  completely  justified  the  operation  and  have  given  great 
relief  to  this  man."     "Quite  well"  in  December,  1907. 

Case  ii. — D.  August  7,  1902.  J.  H.  O.,  male,  aged 
thirty-one.  Pain  after  food  and  gradual  loss  of  weight  tor 
ten  months.  All  solid  food  has  been  abandoned  lit  lie  by 
little,  and  now  fluid  diet  causes  pain.  Occasional  vomiting 
in  large  quantities  and  distension.  Has  twice  had  haemat- 
emesis.  The  pain  is  frequently  felt  about  one  and  one-half 
hours  after  food.  Has  lost  exactly  4  stone  in  the  last  nine- 
teen week-.  A  very  dilated  stomach,  reaching  a  hand's 
breadth  below  the  umbilicus;   free  HC1  present. 

Operation:  Tin-  stomach  and  tit-a  portion  of  the  duode- 
num were  very  markedly  dilated;    a  thickening  of  the  duo- 


340  Duodenal  Ulcer 

denum  just  above  the  bile-papilla  was  felt.  Posterior  gastro- 
enterostomy. Recovery.  Sent  by  Dr.  Norman  Porritt, 
Huddersfield. 

In  June,  1905,  said  he  could  eat  anything  except  a  lot  of 
cheese.  Had  gained  from  8  stone  2  lbs.  to  9  stone  12  lbs.; 
was  therefore  still  below  his  former  weight.  Complained 
of  soon  feeling  tired,  but  had  no  pain  nor  sickness.  Writes 
January  13,  1908:  "I  was  operated  upon  by  you  in  August, 
1902,  but  if  you  remember  I  was  a  long  while  after  the  opera- 
tion and  did  not  receive  much  benefit.  I  have  improved 
more  in  health  during  this  last  nine  months  than  all  the 
other  four  years.  My  weight  was  8  stone  2  lbs.  after  the 
operation  and  I  now  weigh  11  stone.  I  can  now  eat  nearly 
anything  and  at  any  time  without  feeling  any  discomfort. 
When  in  Leeds  I  will  call  and  let  you  have  a  look  at  me ;  you 
will  hardly  know  I  am  the  same  man." 

Case  12. — D.  September  24,  1902.  T.  B.,  male,  aged 
thirty-two.  On  April  9th  patient  was  suddenly  seized  with 
an  acute  attack  of  pain  in  the  right  hypochondrium.  He 
vomited  frequently  and  some  blood  was  noticed.  The 
attack  lasted  two  hours,  and  subsequently  the  motions  were 
seen  to  be  tarry.  Since  then  he  has  suffered  almost  constantly 
from  flatulent  distension,  especially  after  food.  On  several 
occasions  he  has  had  very  severe  attacks  of  pain  in  the  right 
hypochondrium,  lasting  one  to  two  hours  and  doubling  him 
up.  Each  attack  has  been  followed  by  profuse  tarry  stools, 
and  on  two  occasions  has  been  accompanied  by  hsematemesis. 
There  has  never  been  jaundice.  He  has  lost  3^  stone  in 
weight  since  February.  The  stomach  is  a  little  dilated; 
free  HC1  is  in  excess.  Pain  is  chiefly  situated  above  and  to 
the  right  of  the  umbilicus,  and  the  painful  spot  can  be  covered 
by  a  finger-tip. 

Operation:  A  duodenal  ulcer  occupying  the  first  and  second 
portions  of  the  duodenum.  It  was  about  the  size  of  a  walnut, 
very  thick,  and  adherent  to  the  pancreas.  The  gall-bladder 
was  full  of  stones.  These  were  removed  and  a  few  stones 
from  the  hepatic  duct  were  easily  squeezed  along  the  cystic 
duct  into  the  gall-bladder;  the  latter  was  drained  (the  stones 
numbered    1885).     Posterior  gastro-enterostomy.     Recovery. 


Detailed  Statement  of  Cases  Operated  Upon  341 

Patient  was  sent  by  Dr.  McKenzie,  Burnley.  He  was  operated 
on  at  the  Infirmary  for  Mr.  Mayo  Robson. 

Dr.  Crump,  Burnley,  writes  February,  1908:  "In  April, 
1903,  had  an  attack  of  pain  followed  by  jaundice,  but  there 
has  not  been  any  illness  at  all  since  then.  Has  been  able  to 
do  full  duty  ever  since,  and  considers  himself  in  the  pink  of 
health." 

Case  13. — G.  &  D.  September  25,  1902.  B.,  female, 
aged  sixty.  Failing  in  health  for  nine  to  twelve  months.  At 
the  outset  a  sudden  seizure  of  vomiting,  very  acute,  and  last- 
ing over  twenty-four  hours.  There  has  been  a  series  of 
similar  attacks  of  vomiting.  Pain  is  noticed  about  an  hour 
before  a  meal  is  due  and  lasts  from  a  few  minutes  to  two  to 
three  hours;  is  never  very  severe.  She  has  lost  flesh  and  has 
got  weaker,  occasionally  having  to  spend  part  of  the  day  in 
bed.  Xo  melaena,  no  haematemesis.  A^  small  hard  tumour, 
slightly  movable,  felt  above  and  to  the  right  of  the  umbilicus. 
On  distension  with  CO2  an  enormous  stomach,  reaching  a  lull 
hand's  breadth  below  the  umbilicus. 

Operation:  A  very  large  stomach,  on  the  posterior  sur- 
face one  large  ulcer  with  several  thick  adhesions  around  it. 
The  tumour  was  found  in  the  second  portion  of  the  duodenum ; 
it  was  a  mass  about  the  size  of  a  large  walnut,  adherent  to 
the  pancreas,  with  which  it  seemed  inseparably  connected. 
The  duodenum  above  this  point  was  distended.  Probably 
chronic  duodenal  ulcer  with  interstitial  pancreatitis.  Pos- 
terior gastro-enterostomy.  Recovery.  Sent  by  Dr.  Welch, 
Stanningley. 

Dr.  Welch  reports,  June  21,  1905:  "I  saw  Mrs.  B.  to-day; 
she  tells  me  she  has  enjoyed  excellent  health  since  the  opera- 
tion and  has  had  no  stomach  trouble  of  any  sort,  she  cer- 
tainly look-  very  well,  and  she  doe--  all  the  housework  at  her 
own  home." 

Report  February  2,  1908:  "Present  condition  satisfactory; 
slight  gain  in  weight;  practically  no  recurrence  of  pain;  no 
vomiting  excepl  occasional  'bilious  attacks.'  Case  with 
undoubtedly  good  results  of  apparently  permanent  character." 

Case  14.  -1).  October  4,  1002.  Male,  aged  twenty-nine. 
Has  suffered  for  several  years  from  a  "weak  stomach,"  hav- 


342  Duodenal  Ulcer 

ing  pain  two  or  three  hours  after  food  and  occasional  vomiting. 
<  )n  Saturday,  August  31st  last,  had  a  long  bicycle  ride  which 
left  him  very  tired.  On  Sunday  ate  heavily  and  had  much 
discomfort.  At  night  he  got  out  of  bed,  owing  to  the  feeling 
of  fullness  in  the  stomach  and  great  uneasiness.  He  induced 
vomiting  and  the  bowels  were  then  moved.  He  felt  faint  and 
cold.  On  Monday  was  feeling  very  tired  so  did  not  get  up. 
Still  ill  and  weak  on  Wednesday.  The  stools  on  both  days 
were  quite  black.  On  Wednesday  he  fainted  once  when  in 
bed  and  felt  very  chilly.  On  Tuesday  he  had  been  noticed 
to  be  very  pale,  and  his  pallor  increased  decidedly  on  Wednes- 
day. On  Thursday  morning  felt  very  ill  and  dead  tired. 
Pulse  122;  very  blanched.  The  bowels  were  moved  four 
times,  and  large  tarry  stools  passed.  When  seen,  he  looked 
desperately  ill,  the  face  and  buccal  mucous  membrane  being 
blanched  to  the  last  degree.  Chronic  duodenal  ulcer  with 
acute  deepening  and  the  opening  of  some  large  vessel  was 
diagnosed.      Operation  was  advised  as  a  last  resource. 

Operation:  Stomach  was  found  very  dilated  and  full  of 
gas.  It  contained  no  blood.  The  first  portion  of  the  duo- 
denum was  also  dilated,  and  about  1  inch  from  the  pylorus 
a  dense,  hard  mass,  equal  in  size  to  a  walnut,  was  felt  adherent 
to  the  pancreas.  Excision  of  the  ulcer  was  impossible,  and 
therefore  gastro-enterostomy  was  performed.  The  jejunum 
at  the  point  opened  contained  brownish,  altered  blood,  and 
the  transverse  colon  was  a  most  vivid  dark  blue  in  colour 
and  full  of  blood.     Recovery. 

The  patient  was  sent  by  Dr.  Fearnley,  Harrogate.  (When 
lifted  on  to  the  operating  table  the  patient  complained  of 
being  tired  and  cold  and  then  fainted.)  Dr.  Fearnley  reports 
June  26,  1905:  "Went  back  to  work  during  the  first  week 
in  December;  has  not  broken  any  time  from  illness  since, 
but  has  to  be  most  careful  in  his  diet:  more  so  than  before 
the  operation."     No  further  report. 

Case  15. — G.  &  D.  October  6,  1902.  J.  H.  H.,  male, 
aged  thirty.  Symptoms  for  five  years.  Pain  occurring  one 
to  two  hours  after  every  ordinary  meal,  and  occasional  vomit- 
ing. Eructations,  melaena.  During  the  last  six  months  the 
pain  has  been  about  three  hours  after  food,  and  has  always 


Detailed  Statement  of  Cases  Operated  Upon  343 

been  easier  if  a  little  fluid  food  or  a  biscuit  has  been  taken. 
He  is  quite  unable  to  take  ordinary  food,  and  treatment, 
although  carefully  followed  out,  has  not  helped  him.  He  is 
losing  weight  and  is  becoming  progressively  anaemic.  Melsena 
has  not  been  noticed  for  two  months.  Has  a  large,  splashy 
stomach. 

Operation:  Stomach  moderately  dilated.  Scar  of  a  duo- 
denal ulcer  just  beyond  the  pylorus,  with  some  induration 
and  puckering.  On  the  posterior  surface  of  the  stomach 
near  the  pylorus  a  white  scar  the  size  of  a  French  bean. 
Some  adhesions  to  the  upper  part  of  the  transverse  meso- 
colon. Posterior  gastro-enterostomy.  Recovery.  Sent  by 
Dr.  H.  Woodcock,  Leeds.     No  further  report. 

Case  16. — G.  &  D.  October  13,  1902.  J.  H.  B.,  male, 
aged  twenty-eight.  Fourteen  months  ago  an  acute  attack 
of  indigestion  lasting  five  days,  with  'occasional  vomiting; 
no  haematemesis.  He  fainted  several  times  and  had  tarry 
motions.  During  the  last  three  months  has  become  pro- 
gressively worse,  has  lost  over  one  stone  in  weight,  and  has 
constant  pain  after  food,  with  occasional  vomiting;  can  now 
take  only  fluids  and  is  "wearing  down  fast."  A  moderately 
dilated  stomach;  free  HC1.  Old  blood  noticed  almost  daily 
in  the  stools  whilst  in  the  Infirmary. 

Operation:  An  ulcer  about  the  size  of  a  threepenny  piece, 
very  hard  and  slightly  adherent,  was  found  in  the  first  portion 
of  the  duodenum.  A  scar  on  the  posterior  surface  of  the 
stomach  near  the  pylorus.  Posterior  gastro-enterostomy. 
Death  occurred  on  the  tenth  day,  with  symptoms  of  intestinal 
obstruction,  which  at  post-mortem  was  found  to  be  due  to 
hernia  of  almost  the  whole  of  the  small  intestine  through  the 
opening  in  the  transverse  mesocolon.  Patient  was  sent  by 
Dr.  Stamp  Taylor,  Leeds. 

Case  17. — I > .  December  9,  jc>o2.  1.  S.,  female,  aged 
seventeen.  In  April  was  operated  upon  tor  perforation  of  a 
duodenal  ulcer.  For  the  firsl  two  months  all  went  well,  but 
-h'-  was  never  able  to  take  full  diet  freely.  During  the  last 
two  months  the  stomach  ha-  been  very  irritable.  Pain  ami 
discomforl  after  loud  have  gradually  increased  until  now  only 

fluids    are     taken.      Stomach    dilated,   especially    towards   the 

cardiac  end. 


344  Duodenal  Ulcer 

Operation:  Innumerable  adhesions  were  found.  The  pos- 
terior surface  of  the  stomach  could  not  be  traced  on  account 
of  adhesions  of  omentum,  transverse  colon,  etc.;  nor  could 
the  duodenojejunal  flexure  be  reached.  The  caecum  was 
therefore  found  and  the  ileum  traced  upwards  from  it  to  the 
highest  point  of  the  jejunum  free  from  adhesions.  A  Roux's 
operation  was  then  performed  to  the  anterior  surface  of  the 
stomach.  The  caecum  and  colon  were  contained  in  a  mesen- 
tery common  to  them  and  to  the  small  intestine.  Recovery. 
Patient  was  sent  by  Dr.  Wainman,  Leeds. 

By  March,  1903,  she  had  gained  11  lbs.  in  weight.  Report 
received  June  20,  1905:  "Is  now  in  excellent  health,  walking 
three  miles  to  her  work  daily  and  back  again.  In  my  opin- 
ion, she  may  be  considered  cured.  She  has  received  no 
medical  attention  nor  medicine  for  many  months."  Dr. 
Wainman  reports  February  13,  1908:  "Patient  at  regular 
work  in  Leeds  in  moderate  health.  Weight,  8  stone  1  lb., 
a  gain  of  4  or  5  lbs.  She  does  not  go  more  than  a  week  with- 
out some  epigastric  pain,  which  is  increased  if  she  is  not  atten- 
tive to  diet.  Some  pain  and  tightness  in  breathing  after  eat- 
ing is  still  felt,  but  general  health  moderate  and  operation  a 
great  success." 

Case  18. — G.  &  D.  January  17,  1903.  A.  S.,  female,  aged 
twenty-eight.  In  May,  1898,  a  sudden  attack  of  hsematemesis 
and  fainting;  wTas  in  bed  six  weeks.  For  the  next  eighteen 
months  very  poor  health,  indigestion,  vomiting,  and  con- 
stipation; then  six  months  of  good  health.  In  April,  1900, 
indigestion  began  again;  medicinal  treatment  for  six  months 
with  much  benefit.  January,  1902,  hsematemesis,  and  again 
treatment  in  bed  for  four  weeks.  Four  months  ago  another 
attack  of  luematemesis.  Saw  Dr.  Rowling  then  for  first  time 
and  was  in  bed  for  seven  weeks.  During  the  last  few  weeks 
pain  has  occurred  about  an  hour  after  food,  occasionally 
immediately  after.  She  vomits  three  or  four  times  a  day. 
On  examination  epigastric  tenderness,  pressure  causing  a 
pain  through  to  the  back.  No  dilatation  of  stomach;  exces- 
sive free  HO. 

Operation:  An  ulcer  3  or  4  inches  from  the  pylorus  and 
close  to  the  lesser  curvature.     It  was  as  large  as  a  shilling, 


Detailed  Statement  of  Cases  Operated  Upon  345 

very  dense,  and  adherent  to  the  pancreas  behind.  A  second 
ulcer,  about  ^4  inch  in  diameter,  in  the  duodenum  just  beyond 
the  pylorus.  Posterior  gastroenterostomy.  Recover}-.  Sent 
by  Dr.  Rowling,  Leeds. 

By  March  she  had  gained  5  lbs.  in  weight,  eating  well. 
Report  received  from  Dr.  Rowling,  June  26,  1905,  says: 
"I  can  eat  almost  anything  without  it  hurting  me.  I  don't 
have  the  pain  nor  yet  the  vomiting  I  used  to  have.  Did  not 
want  to  live  before;  quite  the  opposite  now.  Would  willingly 
undergo  the  same  operation  again.  Gained  three  stone  since 
operation." 

Report,  1908:  Stout,  looks  fairly  well,  but  somewhat 
anaemic.  Gained  2  stone  in  weight.  Has  vomited  more  or 
less  ever  since  the  operation;  nearly  every  morning  direct ly 
she  gets  out  of  bed.  Vomit  is  described  as  bitter  and  bright 
yellow,  and  at  times  very  dark,  like  coffee.  Cannot  take  food 
in  the  morning,  but  enjoys  the  mid-day  meal.  Complains 
of  a  burning  pain  in  the  chest,  with  palpitation  and  a  hot 
froth  rising  into  the  mouth.  Is  very  costive  and  the  stomach 
symptoms  are  relieved  by  suitable  aperient.  The  patient 
says  she  is  better  by  far  since  the  operation;  it  made  the 
difference  between  being  unable  to  work  before,  and  able  to 
work  after.  The  result  is  good,  but  all  the  stomach  symptoms 
have  not  been  entirely  removed. 

CASE  19. — G.  &  D.  January  22,  1903.  J.  E.,  male,  aged 
forty-seven.  In  January,  1902,  when  returning  from  1  .  s 
Palmas,  had  a  severe  attack  of  mekena.  Several  years  before 
this  had  been  subject  to  indigestion  and  inability  to  eat  heart- 
ily, but  for  a  few  months  before  the  attack  of  bleeding  had 
been  in  better  health  than  usual.  Since  this  attack  has  had 
many  others  of  melaena  and  hamiatemesis.  Has  been  in  a 
Nursing  Home  in  London  for  thirteen  weeks  under  treatment 
lor  duodenal  ulcer.     While  there  had  occasional  severe  bleed 

ingS   and    his    haemoglobin    count    was   only    [8    per   cent.      On 

examination  he  was  very  thin  and  anaemic.     A  dilated,  obvi 
ously  contracting  stomach  was  seen,  from  which  he  shortly 

afterwards    vomited    a    quart    of    fluid    Containing    blood.       He 

looked  extremely  worn  and  ill,  and  it  was  necessary  to  infuse 
saline  solution  during  and  after  the  operation,  lie  had  co]  i- 
011s  melaena  during  the  <l,i\  ami  nighl  before  operation. 


346  Duodenal  Ulcer 

Operation:  An  enormous  stomach,  slightly  hypertrophied. 
The  first  portion  of  the  duodenum  was  embedded  in  a  mass 
equal  in  size  to  a  lemon  (inflammatory  thickening  round  an 
ulcer).  On  the  greater  curvature  near  the  pylorus  an  ulcer 
the  size  of  a  shilling.  Posterior  gastro-enterostomy.  Recov- 
ery. The  patient  was  sent  by  Dr.  Bampton,  Ilkley,  and 
seen  in  consultation  with  Dr.  Barrs.  Was  soon  able  to  take 
ordinary  diet.  In  the  fifth  week  a  severe  attack  of  diarrhoea 
lasting  four  days.  By  March,  1903,  had  gained  7  lbs.  By 
July,  1903,  had  gained  4  stone  and  could  eat  heartily. 
Quite  well  in  July,  1904,  and  maintaining  his  weight. 

June,  1905,  Dr.  Bampton  reviews  the  whole  progress  in 
this  way:  "Recovery  was  uninterrupted,  but  during  con- 
valescence patient's  appetite  was  so  voracious  that  he  thought 
he  could  eat  anything  and  everything  in  any  quantity;  in 
consequence  Mr.  E.  had  two  or  three  vomiting  attacks  of 
considerable  quantities  of  bile.  Since  learning  wisdom  has 
had  no  gastric  disturbance  of  any  kind  and  is  able  to  eat 
ordinary  meals  with  more  comfort  than  he  has  experienced 
for  fifteen  years.  Plays  golf,  rows,  bicycles,  takes  long  walks, 
and  maintains  his  weight.  In  every  respect  the  operation 
has  been  a  complete  success,  and  shews  that  nutrition  improves 
in  spite  of  the  short-circuiting.  From  this  and  other  experi- 
ence I  think  that  in  recurring  haemorrhage  from  gastric  or 
duodenal  ulcer  operation  should  be  the  rule  just  as  much  as 
it  is  in  recurring  appendicitis." 

Report  February  22,  1908:  "In  very  good  health;  main- 
tains weight,  feels  well,  and  can  enjoy  a  ten-mile  walk,  and 
says:  'I  shall  be  very  pleased  and  grateful  if  I  am  allowed  to 
end  my  days  in  the  comfort  I  now  enjoy,  and  I  am  doing  my 
best  to  negotiate  a  long  term  of  years.'" 

Case  20. — G.  &  D.  February,  1903.  Mrs.  S.,  aged  fifty- 
six.  In  February,  1892,  was  in  the  Infirmary  for  the  removal 
of  an  ovarian  cyst.  In  the  notes  it  is  said  that  the  patient 
then  suffered  much  from  indigestion,  and  on  one  occasion 
had  melaena.  Since  then  Dr.  Woods  has  attended  her  for 
chronic  indigestion.  On  several  occasions  there  has  been 
severe  melaena.  In  1887  a  medical  man  diagnosed  an  acute 
illness  as  "ulcerated  stomach."     An  attack  of  haematemesis 


Detailed  Statement  of  Cases  Operated  Upon  347 

in  December,  1901.  In  September,  1902,  a  prolonged  attack 
of  melsena.  Now  has  pain  two  or  three  hours  after  a  meal 
all  over  upper  part  of  abdomen,  and  frequently  "heaving 
and  vomiting";  can  take  nothing  solid  except  biscuits.  Dur- 
ing the  last  twelve  months  has  lost  over  3  stone  in  weight 
and  has  persistent  anaemia. 

Operation:  A  mass  the  size  of  a  Tangerine  orange  was 
found  in  the  first  portion  of  the  duodenum.  Milky  opacity 
of  the  overlying  peritoneum.  In  the  stomach,  near  the 
greater  curvature,  about  4  inches  from  the  pylorus,  an  ulcer  the 
size  of  a  sixpence.  The  omentum  was  crumpled  up  and  adher- 
ent to  it.  Posterior  gastroenterostomy.  Recovery.  Sent 
by  Dr.  Woods,  Batley. 

Report  received  from  Dr.  Woods  June  26,  1905:  "Better 
now  than  she  has  been  for  years;  perfectly  well."  Report 
January,  1908:  "In  excellent  health;  ,able  to  do  her  house- 
work, wash,  bake,  clean,  etc.;  slight  gain  in  weight.  No 
recurrence  of  pain  nor  vomiting."  Remarks:  "Source  of 
income  to  general  practitioner  cut  off." 

Case  21. — G.  &  D.  February  19,  1903.  G.  B.,  male, 
aged  sixty-two.  Has  suffered  from  indigestion  and  vomiting 
for  several  years.  Says  he  does  not  remember  when  he  was 
able  to  take  an  ordinary  meal  in  comfort.  Three  years  ago 
was  seen  by  a  physician,  who  diagnosed  pyloric  stenosis  and 
gastric  dilatation  and  advised  operation.  Since  then  the 
vomiting  and  pain  have  increased  to  such  a  degree  that  the 
patient  says  he  cannot  go  on  any  longer.  On  examination 
an  enormous  stomach,  actively  contracting. 

Operation:  A  large,  hypertrophied  stomach  shewing  several 
scars.  The  pyloric  region  on  both  gastric  and  duodenal  side 
was  scarred  and  stenosed.  Posterior  gastro-enterostomy. 
Recovery.     Sent  by  Dr.  Adam,  Sowerby  Bridge. 

Report  received  from  Dr.  Adam  June  2(>,  1005:  "B.  is  in 
apparently  perfeel  health.  Works  overtime  as  a  dyer's 
labourer  without  special  fatigue.  Eats  well  and  sleeps  well, 
and  has  kept  a  regular  weight  of  11  stone  tor  twelve  months. 
Weighl  before  operation,  8^  stone.  No  return  of  stomach 
trouble,  and  he  told  me  yesterday  he  never  fell  better  in  his 
lite     The  result   ol   operation   has  been   particularly  happy. 


348  Duodenal  Ulcer 

The  man  had  been  going  his  rounds  for  some  years  trying  all 
sorts  of  treatment  by  medical  men,  and  latterly  had  used  a 
stomach-pump  almost  daily.  He  was  most  despondent  and 
threatened  to  commit  suicide,  and  I  have  reason  to  believe 
he  would  have  carried  out  this  threat  if  he  had  not  been  re- 
lieved by  operation.  In  my  opinion  the  operation  would 
almost  have  been  justified  for  the  relief  of  mental  symptoms 
apart  from  the  relief  of  pain,  sickness,  and  distress,  etc.,  and 
increase  of  strength  and  ability  to  work  hard  and  support 
himself  and  family." 

Report  January  27,  1908 :  "  Never  better  in  his  life ;  present 
weight,  11  stone  12  lbs.  No  recurrence  of  pain ;  has  vomited 
about  half  a  dozen  times  since  operation,  and  on  each  occa- 
sion this  was  due  to  overeating  or  to  something  wrong  with 
what  he  had  taken.  The  vomit  consisted  simply  of  the  food 
taken.  (The  man  is  fond  of  good  living.)  This  is  certainly 
a  remarkable  result  considering  the  condition  of  the  man  for 
some  years  previous  to  operation.  He  is  at  present  working 
long  hours  as  a  dyer's  labourer,  has  averaged  sixty-eight  to 
seventy  hours  per  week  for  some  time— by  no  means  a  bad 
record  for  a  man  of  sixty-seven  years." 

Case  22. — G.  &  D.  April  11,  1903.  E.  L.,  female,  aged 
nineteen.  Her  first  symptoms  were  observed  in  1901.  Quite 
at  the  beginning  an  attack  of  haematemesis.  Was  then  under 
careful  treatment  for  over  six  weeks.  On  beginning  to  take 
solid  food  pain  was  noticed,  generally  half  an  hour  after  a 
meal.  Pain  and  vomiting  are  now  constant  after  all  solid 
food,  so  that  for  several  months  she  has  lived  entirely  on 
fluids.  For  over  three  months  now  pain  has  become  increas- 
ingly severe  and  she  has  given  up  her  work.  Recently  a  slight 
attack  of  haematemesis.     Stomach  slightly  dilated. 

Operation:  An  ulcer  about  1  inch  below  the  lesser  curvature 
near  the  cardia;  some  adhesions  around  pylorus  and  duo- 
denum. Posterior  gastroenterostomy.  Recovery.  Patienl 
was  sent  by  Dr.  Goode,  Doncaster. 

Report  received  from  Dr.  Goode  June  21,  1905:  "I  saw 
E.  L.  not  long  ago,  when  she  was  wonderfully  well.  She  never 
complains  of  indigestion  now,  and  on  the  last  occasion  she 
consulted    me    it    was    merely    for   a    severe    cold."     Report, 


Detailed  Statement  of  Cases  Operated  Upon  349 

February  26,  1908:  "Patient  is  in  good  health,  gained  in 
weight,  no  recurrence  of  pain  nor  vomiting.  Married  and  has 
two  children." 

Case  23. — G.  &  D.  April  19,  1903.  H.  J.,  male,  aged 
twenty-seven.  Symptoms  of  indigestion  for  five  or  six  years. 
A  feeling  of  weight  and  oppression  in  the  epigastrium  after 
food.  "Rifting,"  sour  eructations.  Often  feels  the  food 
"working  about  in  the  stomach."  Has  very  little  appetite. 
Has  occasionally  had  periods  during  which  an  intense  burning 
pain  has  been  felt  about  two  or  three  hours  after  a  meal.  Has 
lost  1 3^2  stone  in  the  last  five  years.  During  the  last  six 
months  the  symptoms  have  been  more  severe,  almost  pre- 
venting him  from  doing  his  work.  The  stomach  is  dilated,  but 
no  peristalsis  is  visible. 

Operation:  Stomach  dilated.  A  few  scars  of  gastric  ulcers 
on  the  posterior  surface  of  the  stomach  near  the  pylorus.  A 
duodenal  ulcer  the  size  of  a  sixpence.  Posterior  gastro- 
enterostomy. Recovery.  He  had  a  severe  attack  of  bronchi- 
tis after  the  operation,  with  high  temperature  and  rapid  pulse. 
By  October,  1904,  had  gained  9  lbs.  The  patient  was  sent 
by  Dr.  Rowden,  Roundhay. 

Dr.  Rowden  reports,  June  20,  1905:  "Was  relieved  by 
operation,  but  remained  very  unwell  until  six  months  ago; 
since  then  he  has  been  very  much  better."  Report  February 
3,  1908:  "Present  condition  very  fair,  but  anaemic;  weight 
about  the  same.  Some  recurrence  of  pain.  He  still  has  to 
be  careful  in  his  diet  or  he  has  considerable  discomfort  from 
distension  and  flatulence.  I  do  not  think  there  has  been  any 
vomiting.  The  operation  has  certainly  improved  the  pa- 
1  i m  's  condition,  but  not  to  the  extent  one  would  have  hoped. 
Stomach  is  still  very  considerably  dilated." 

CASE  24. — D.  June  9,  1903.  J.  R.,  male,  aged  thirty. 
AIkhi!  fifteen  months  ago  first  noticed  a  sharp,  burning  pain 
in  the  epigastrium,  a  little  to  the  left  of  the  middle  line.  This 
was  worse  after  food  at  first,  but  latterly  he  has  had  most  pain 
when  fasting.  Now  feels  easy  when  .1  moderate  meal  is 
taken,  but  in  about  an  hour  has  "very  bitter  belching  and 
water  brash,"  and  then  pain  becomes  steadily  more  acute. 
I  la--  vomited  rarely  until  recently.     I>  now  losing  weighl 


35°  Duodenal  Ulcer 

I  stone  in  the  last  five  weeks.  The  stomach  is  slightly 
dilated. 

Operation:  An  ulcer  in  the  first  portion  of  the  duodenum, 
about  i  inch  beyond  the  pylorus;  a  hard  pellet  of  scar  tissue 
in  posterior  wall  of  stomach,  2  or  3  inches  from  the  pylorus. 
Posterior  gastro-enterostomy.  Recovery.  Patient  was  sent 
by  Dr.  Crump,  Burnley.  Weight  before  operation,  8  stone 
3  lbs.;  September  9,  1903,  8  stone  8  lbs.;  September  3,  1904, 
9  stone  1  lb. 

Report  received  from  Dr.  Crump  June  28,  1905:  "He  will 
not  admit  that  he  is  any  better  since  the  operation,  but  you 
know  he  is  neurasthenic,  and  the  fact  that  he  is  able  to  work 
regularly  proves  to  my  mind  that  he  is  better."  (For  further 
progress  of  case  and  report,  see  Case  40.) 

Case  25.— D.  June  23,  1903.  C.  B.,  male,  aged  thirty- 
one.  Has  been  suffering  from  "indigestion"  for  two  or  three 
years.  About  three  hours  after  a  meal  begins  to  fell  a  sinking 
sensation,  with  pain  and  burning  in  the  epigastrium,  which  is 
eased  by  gentle  pressure  of  the  hand.  Pain  and  tenderness 
to  the  right  of  the  middle  line.     Stomach  slightly  dilated. 

Operation:  A  duodenal  ulcer,  about  A  of  an  inch  in  diameter, 
with  opaque  surface  and  hard,  puckered  base,  just  beyond  the 
pylorus.  Posterior  gastro-enterostomy.  Recovery.  Patient 
sent  by  Dr.  Baxter  Tyrie,  Keighley.  Dr.  Kammerer  and  Dr. 
Brewer,  of  New  York,  present. 

Seen  by  me  in  November,  1904.  After  the  operation 
suffered  for  three  months  from  "acidity,"  for  which  a  bis- 
muth and  morphin  mixture  and  carbonate  of  soda  were  given. 
For  twelve  months  has  been  quite  well.  Appetite  very  good. 
Eats  hearty  meals  and  has  gained  15  lbs.  in  weight.  Seen  by 
me  January,  1908:  "Never  a  bit  of  trouble  since  the  opera- 
tion." 

Case  26. — D.  July  14,  1903.  H.  L.  R.,  male,  aged  forty- 
two.  Many  years'  indigestion.  Pain,  burning,  and  fullness 
after  meals.  Pain  comes  on  about  two  hours  after  a  meal, 
and  lasts  till  next  meal,  when  he  is  easy  for  a  time.  Pain 
goes  round  the  right  side  of  the  abdomen  and  through  to  the 
back.  Recently  has  become  much  worse;  suffers  from  a 
heavy,  burning  feeling  in  the  pit  of  the  stomach,  and  cannot 


Detailed  Statement  of  Cases  Operated  Upon  351 

eat  with  comfort.  No  vomiting.  Very  tender  to  the  right, 
of  the  epigastrium. 

Operation:  A  duodenal  ulcer,  reddened,  indurated,  and 
slightly  puckered,  was  found  just  beyond  the  pylorus;  a  few 
adhesions  upon  the  posterior  surface  of  the  stomach.  Pos- 
terior gastroenterostomy.  Recovery.  Patient  sent  by  Dr. 
Griesbach,  Garforth. 

Report  June  13,  1905:  "Gained  steadily  in  weight  since 
the  operation.  Eats  well,  has  no  sickness,  and  is  in  good 
general  health."  Report  September  1,  1908:  "Stronger, 
but  still  has  a  hot  feeling  in  the  stomach  every  now  and  again. 
Has  gained  7  or  8  lbs.  in  weight.  Occasionally  feels  sickly, 
perhaps  every  four  or  five  months,  for  a  few  hours.  Xo 
vomiting.  Takes  ordinary  food  and  has  a  good  appetite. 
Sums  up  the  improvement  since  the  operation  by  saying 
he  'is  a  great  credit  to  me.'  "  t 

Case  27. — G.  &  D.  July  25,  1903.  R.,  male,  aged  thirty. 
For  several  years  has  suffered  on  and  off  from  indigestion  and 
had  to  be  careful  and  sparing  in  his  diet.  Two  months  ago, 
whilst  in  Sheffield,  had  profuse  haematemesis  and  for  several 
days  melaena.  He  fainted.  Since  then  has  been  kept  in  bed 
upon  very  small  quantities  of  liquid  food,  but  these  give  him 
pain,  and  any  attempt  at  increase  causes  vomiting. 

Operation:  A  duodenal  ulcer  was  found  immediately 
beyond  the  pylorus;  a  dense  white,  very  hard  scar  of  a  gastric 
ulcer  near  the  greater  curvature,  about  3  inches  from  the 
pylorus.  Posterior  gastroenterostomy.  Recovery.  Patient 
was  sent  by  Dr.  Hawkyard,  Leeds. 

Report  June  20,  1905:  "  R.  is  in  good  health  and  follow- 
ing the  occupation  of  tram  conductor."  Report  March  (>, 
[908:  "R.  is  much  better;  in  fact,  is  quite  well,  and  he  eats 
anything;  no  vomiting,  no  pain.  In  the  first  twelve  months 
after  operation  he  had  several  attacks  of  vomiting,  some  last- 
in-  t  wo  or  three  days.  Evidently  food  got  into  the  duodenum, 
and  not  being  able  to  pass  onward,  was  with  great  difficulty 
ejected.     For  eighteen   months  after   the  operation   he   was 

not  Strong,  and  did  not  go  back  to  his  old  job.  Since  then 
he  has  worked  .it    his  own   trade,  and    I   am   told   lie  i-  ,i-  well 

,1-  ever,  and  has  no  inconvenience  of  any  kind.     Have  not 


352  Duodenal  Ulcer 

seen  him  for  some  time,  as  he  is  living  in  Sheffield."  (A case 
of  temporary  regurgitation.) 

Case  28. — D.  August  17,  1903.  L.,  male,  aged  thirty- 
nine.  Some  years  ago  patient  had  five  or  six  attacks  of 
severe  abdominal  pain  with  fainting.  The  last  of  these  was 
four  years  ago.  On  July  27,  1903,  he  had  another  simibr 
attack  of  pain,  and  nearly  fainted.  The  pain  passed  off 
after  about  half  an  hour.  On  August  I,  1903,  whilst  cycling 
home  from  business,  he  felt  faint  and  got  off  his  bicycle.  He 
vomited  a  large  quantity  of  blood.  On  reaching  home  he 
collapsed.  Next  day  he  again  vomited  blood  and  had  several 
black  stools.     He  is  very  anaemic;    pulse  120. 

Operation:  An  ulcer  adherent  to  the  pancreas  was  found  on 
the  posterior  wall  of  the  second  part  of  the  duodenum.  Pos- 
terior gastro-enterostomy.  Recovery.  Patient  was  severely 
collapsed  after  the  operation.     Sent  by  Dr.  Oldfield,  Leeds. 

Dr.  Oldfield  writes,  March  26,  1905:  "Am  pleased  to  say 
that  Mr.  L.  is  very  well  indeed.  As  far  as  I  know  he  has  not 
been  off  work  a  single  day  since  he  resumed  after  the  opera- 
tion. He  takes  ordinary  food,  his  supper  usually  consisting 
of  cheese,  bread,  salad,  and  beer.  There  have  been  one  or 
two  rather  sharp  attacks  of  diarrhoea,  but  no  vomiting,  and 
no  blood  has  been  lost." 

Report  February,  1908:  "In  perfectly  good  health;  slight 
loss  of  weight.  For  three  years  after  the  operation  he  had 
occasional  attacks  of  severe,  colicky  pain  in  the  abdomen, 
lasting  half  an  hour,  and  followed  by  a  sharp  attack  of  diar- 
rhoea. These  have  become  more  infrequent  lately.  There 
has  been  no  vomiting.  Has  never  had  a  day  off  work  for 
reasons  of  abdominal  trouble  since  he  commenced  work  after 
the  operation,  with  the  exception  of  once  last  summer,  when 
he  had  an  attack  of  diarrhoea." 

Case  29. — G.  &  D.  September  17,  1903.  Mrs.  H.,  aged 
forty-nine.  Seventeen  years  ago  had  severe  "indigestion" 
with  occasional  vomiting;  never  jaundiced.  Then  remained 
fairly  well  up  to  two  years  ago;  then  occasional  "spasms." 
During  the  last  twelve  months  a  return  of  pain,  which  has 
been  steadily  getting  worse.  She  has  had  a  severe  attack  of 
pain  and   vomiting  every  week  recently.     Pain  was  in   the 


Detailed  Statement  of  Cases  Operated  Upon  353 

epigastrium  and  tended  to  pass  to  the  left.     She  has  been  on 
liquid  food  since  May,   1903,  and  has  lost  1  stone  in  weight. 

Operation:  Many  adhesions  fixing  the  under  surface  of 
liver  and  gall-bladder  to  duodenum;  small  scar  on  front  of 
pylorus.  A  hard  mass  size  of  a  small  walnut  was  felt  about 
2  inches  along  the  duodenum.  It  could  not  be  exposed  be- 
cause of  the  universal  adhesions,  but  was  thought  to  be 
a  chronic  ulcer.  Posterior  gastroenterostomy.  Recovery. 
Patient  was  sent  by  Dr.  Rolf,  Huddersfield. 

Report  from  Dr.  Rolf,  June  26,  1905:  "The  operation  has 
been  most  successful.  Mrs.  H.  has  had  no  gastric  symptoms 
of  importance  since  the  operation.  At  present  she  is  in  good 
health.  She  is  able  to  travel  and  to  attend  to  all  the  duties  of 
her  life.  She  has  increased  considerably  in  weight."  Seen 
in  November,  1907:  "Perfectly  well,"  Dr.  Rolf  reports 
January  25,  1908:  "In  good  health;  gain  of  about  I x/l  stone 
in  weight.  Xo  recurrence  of  pain  nor  vomiting.  Mrs.  H. 
has  been  greatly  improved  by  the  operation,  and  has  had  no 
marked  gastric  symptoms  since  it  was  done,  although  she 
has  to  be  very  careful  of  her  diet.  Her  case  may  be  looked 
upon  as  a  marked  success." 

Case  30. — D.  November  23,  1903.  R.  B.,  male,  aged 
thirty.  Quite  well  up  till  eighteen  months  ago,  when  he 
had  an  attack  of  pain  below  and  to  the  right  of  the  umbilicus, 
accompanied  by  vomiting.  These  symptoms  have  continued 
at  intervals  up  until  now.  Latterly  he  has  vomited  only  at 
night.  Dieting  did  not  improve  the  condition.  No  haemat- 
emesis  nor  melaena  has  been  noticed,  although  looked  for 
recently. 

Operation:  Thickening  and  puckering  of  an  old  ulcer  in 
the  first  part  of  the  duodenum.  Posterior  gastro-enterostomy. 
Recovery.     Sent  by  Dr.  Ellis,  Halifax. 

Dr.  YA\\>  reports  June  20.  1905:  "Very  well  indeed." 
Dr.  Ellis  reports  February  26,  [908:  "This  man.  so  far  as  his 
stomach  is  concerned,  did  remarkably  well.  He  died  lasl 
year  from  cardiac  disease." 

Case  31.     G.  &  l>.     December  2,  [903.     P.  W.,  male, 
thirty-five.     For  two  or  three  years  had  slight  pain  and  dis- 
comforl  after  food,  with  foul  and  -our  eructation.     He  began 
to  \01nit  about  one  year  ago,  the  act  being  sometimes  induced 
23 


J54  Duodenal  L  leer 

in  order  to  relieve  hi>  pain.  No  haematemesis  nor  melaena 
noticed.     The  stomach  reaches  one  inch  below  the  umbilicus. 

Operation:  Scar  of  an  old  ulcer  on  the  posterior  surface  of 
the  stomach  near  the  lesser  curvature.  An  ulcer  about  the 
>\zc  of  a  sixpence  also  present  in  the  concavity  of  the  first 
part  of  the  duodenum.  Posterior  gastroenterostomy.  Re- 
covery.    Sent  by  Dr.  Exley.  Leeds. 

Report  June  26.  1905:  "  Perfectly  well;  no  symptoms  at 
all;  gain  in  weight;  quite  fat."  Report  February  13.  1908: 
"Present  condition  very  good;  gain  in  weight.  Xo  recurrence 
of  pain  nor  vomiting.  I  saw  this  patient  a  week  or  so  ago,  and 
he  told  me  he  had  never  been  better  in  his  life." 

Case  32. — D.  December  2,  1903.  E.  B..  female,  aged 
forty-five.  Pain  after  food  and  occasional  vomiting  for  ten 
years.  Much  worse  during  the  last  three  months.  Has  lost 
1  stone  in  weight  during  the  last  eight  months.  Examina- 
tion of  stomach  contents  after  test-meal  shewed  absence  of 
free  HC1  and  presence  of  lactic  acid. 

Operation:  A  thickened  band  was  found  passing  across  the 
front  of  the  first  part  of  the  duodenum.  Many  omental 
adhesions  to  anterior  abdominal  wall.  Posterior  gastroenter- 
ostomy. Recovery.  She  was  sent  by  Dr.  McXab,  Armley. 
This  patient  has  not  been  traced  recently.  She  was  last  seen 
about  five  or  six  months  after  the  operation,  and  was  then  in 
good  health. 

Case  33. — D.  December  3.  1903.  A.  P..  female,  aged 
thirty-eight.  Has  had  symptoms  on  and  off  for  ten  years, 
becoming  worse  lately.  Symptoms  consist  of  vomiting,  pain 
in  the  left  side,  and  nausea.  Pain  is  always  present,  but 
worse  after  food.  Vomiting  makes  the  pain  worse,  and  the 
patient  says  she  has  sometimes  vomited  a  little  blood.  The 
bowels  are  constipated  and  she  has  lost  weight  I  present  weight. 
5  -tone  4]o  lbs.).  Present  condition:  frequent  vomiting, 
tenderness  in  left  hypochondrium.  free  HC1  in  stomach  con- 
tents after  test-meal.  Urine,  acid:  sp.  gr.,  1018;  albumen; 
no  sugar. 

Operation:  Nothing  abnormal  found.  No  scars  visible  in 
stomach  or  duodenum.  Posterior  gastroenterostomy.  The 
patient  developed  hematuria  and  uraemic  symptoms,  and 
died  on  December  8th.     She  wa-  sent  by  Dr.  Woodcock.  Leeds. 


Detailed  Statement  of  Cases  Operated  Upon 


'Post-mortem  report:  No  peritonitis:  anastomosis  quite 
sound.  "  Kidneys  are  small  and  present  cysts  on  their  sur- 
face. The  capsules  did  not  strip  readily,  being  adherent  in 
some  places.  On  passing  the  finger  over  the  kidney  surface 
a  distinctly  granular  impression  is  imparted  to  it.  The  cortex 
is  extremely  narrow,  almost  all  the  kidney  surface  being  made 
up  of  the  pyramids.  The  pelves  appear  normal."  There  was 
ulceration  without  induration  in  the  duodenum,  probably 
uraemic  in  origin. 

■Case  34. — G.  &  D.  December  23.  1903.  P.  H..  male,  aged 
twenty-eight.  Six  years'  indigestion:  pain  in  epigastrium 
and  between  shoulders  after  food.  Much  troubled  by  a 
feeling  of  distension;    no  vomiting. 

Operation:  A  large  scar,  with  thickening  on  the  posterior 
surface  of  the  stomach:  also  considerable  induration  in  the 
duodenum.  Posterior  gastroenterostomy.  Recovery.  Sent 
by  Dr.  Mackenzie,  Leeds. 

Came  with  another  patient  March.  1906,  and  said  he  had 
been  quite  well  since  the  operation,  except  that  he  vomited 
"a  lot  of  bile"  for  about  six  months.  (A  case  of  temporary 
regurgitation.) 

SE  35. — D.  January  15.  1904.  J.  H..  male,  aged  thirty- 
two.  Symptoms  for  three  or  four  years.  Pain  at  first  whilst 
eating:  latterly  it  has  occurred  an  hour  or  so  after  food. 
Vomiting  for  eighteen  months.  Loss  of  weight,  I J^  stone. 
Xo  haematem      - 

Operation:  Adhesions  of  pylorus  and  duodenum  to  the 
gall-bladder;  duodenum  dilated.  Posterior  gastro-enter<>-- 
tomy.     Recovery. 

Was  seen  at  the  Infirmary  in  January.  [905,  when  he  came 
t<>  >hew  himself  as  a  good  result.  He  writes.  January  26,  1908: 
I  un  very  pleased  to  say  that  I  am  enjoying  very  excellent 
health.  I  have  no  trouble  whatever  with  my  stomach.  I  am 
ng  rough  food,  but  keep  off  pastry  and  sweet  stuff.  I  haw- 
worked  as  a  labourer  in  the  foundry  for  the  last  twelve  month>. 
and  I  have  not  lost  a  day  from  illness.  The  work  is  heavy 
and  labourious,  so  I  consider  it  i-  a  -  :1  cure,  for  which 

I  am  very  grateful." 

<"\~i    36.      1).     January-  20.  [904.     J.  S.,  mail  forty. 


356  Duodenal  Ulcer 

Has  suffered  from  pain  in  the  epigastrium  for  eighteen  years. 
During  the  last  three  years  this  has  got  worse  and  he  has  had 
occasional  attacks  of  vomiting.  For  six  months  the  pain  has 
been  very  severe  and  he  has  lost  1  stone  in  weight.  No  ire*.' 
I  KM  present  in  stomach  contents. 

Operation:  A  duodenal  ulcer  the  size  of  a  threepenny  piece 
was  found  just  beyond  the  pylorus.  Posterior  gastroen- 
terostomy. Recovery.  He  was  sent  by  Dr.  Beegling,  Hud- 
dersfield. 

On  September  16,  1904,  seen  by  Dr.  Douglas  Turner: 
"Little  or  no  improvement."  In  June,  1905,  seen  by  Dr. 
Hogarth,  Morecambe:  "Still  troubled  a  good  deal  with 
flatulence  and  only  slightly  better  for  the  operation."  Dr. 
Hogarth  writes,  March  13,  1908:  "This  patient  only  consulted 
me  once  casually,  but  on  enquiring  I  heard  that  he  continued 
in  an  unsatisfactory  state  for  some  time,  then  went  to  Canada. 
When  last  heard  of,  he  was  considerably  better,  that  is,  a  few 
months  ago." 

Case  37. — G.  &  D.  January  27,  1904.  M.  S.,  female,  aged 
sixty-one.  For  the  last  three  months  pain  and  fullness  after 
food,  but  no  vomiting.  Pain  comes  about  half  an  hour  after 
food.  Stomach  is  dilated  and  a  tumour  can  be  felt  beneath 
the  upper  part  of  the  right  rectus. 

Operation:  A  large  hypertrophied  stomach  with  consider- 
able inflammatory  deposit  around  the  pylorus  and  duodenum. 
No  gall-stones.  Posterior  gastroenterostomy.  Recovery. 
Patient  was  sent  by  Dr.  Clarke,  Doncaster. 

Report  received  June  20,  1905:  She  is  doing  her  duties  and 
is  practically  well.  Dr.  Clarke  reports,  February  3,  1908: 
"Patient  is  very  well;  has  gained  a  stone  or  more  in  weight. 
There  was  recurrence  of  pain  for  about  one  year  and  a  halt. 
Pain  appeared  to  be  caused  by  the  bowels,  for  every  time  they 
acted  she  had  pain.  She  had  to  be  very  careful  of  her  food  for 
two  years  and  was  troubled  greatly  with  wind.  No  vomiting 
except  an  occasional  bilious  attack.  Feels  better  than  she 
has  for  several  years.     She  looks  very  well." 

Case  38. — D.  March  24,  1904.  C.  E.  M.,  female,  aged 
twenty-five.  Indigestion  for  twelve  years.  For  many  years 
ha--  had  acid  eructations,  and  for  the  last  two  years  has  vomited 


Detailed  Statement  of  Cases  Operated  Upon     357 

after  food.  Has  had  many  severe  attacks  of  epigastric  pain. 
Four  days  before  admission,  and  again  one  day  before,  she 
had  attacks  of  pain,  but  not  more  acute  than  many  she  had 
before.  During  the  last  three  years  her  weight  has  dropped 
from  9  stone  to  5  stone  8%  lbs. 

Operation:  An  ulcer  the  size  of  half  a  crown  on  the  upper 
aspect  of  the  first  portion  of  the  duodenum,  with  a  perforation 
the  size  of  a  small  pea.  There  was  a  little  local  plastic  peri- 
tonitis, but  no  general  infection.  The  perforation  was  closed 
by  Lembert's  sutures  and  a  posterior  gastro-enterostomy 
performed.     Recovery.     She  was  sent  by  Dr.  Rowling. 

Report  from  Dr.  Rowling  June  26,  1905:  Gained  2^  stone 
in  weight  during  the  three  months  succeeding  the  operation. 
Expresses  herself  as  being  "a  great  deal  different  from  what  I 
was  eighteen  months  ago."  Says  of  the  operation  that  it 
certainly  was  a  success  and  saved  her' life. 

Dr.  Rowling  reports  February  15,  1908:  "Patient  died 
July  22,  1907.  Gained  weight  during  the  ten  months  succeed- 
ing operation — about  ij^  stone;  then  began  to  lose  weight 
until  she  died.  For  the  first  ten  months  after  the  opera" 
tion  there  was  no  pain,  but  it  then  recurred.  At  first  the 
pain  was  felt  at  comparatively  long  intervals  and  lasted 
only  a  short  time.  It  is  described  by  the  husband  as  a  drag- 
ging pain  across  the  pit  of  the  stomach;  later  the  pain  became 
more  severe  and  more  frequent.  In  the  first  ten  months 
no  vomiting.  For  the  next  eight  months  water-brash  at 
times;  then  occasionally  vomited  until  nine  months  before 
death,  when  it  ceased.  Vomit  bright  yellow  colour.  On 
standing,  a  layer  of  fat  rose  to  the  top.  Sometimes  contained 
coffee-ground  material,  never  any  bright  blood.  Suffered 
from  constipation,  especially  during  the  last  twelvemonths 
of  life." 

Report  by  Dr.  Wainman,  of  Leeds:  "There  was  gradual 
wasting  during  the  last  year  of  life,  with  marked  anaemia  and 
.1  gradually  developing  ascites  and  inability  to  retain  or 
digesl  food.  Death  occurred  from  asthenia  and  exhaustion. 
Cause  of  death  was  probably  carcinoma  of  the  stomach." 
(Ulcus  carcinomatosum?)    Three  and  one-third  years'  interval. 

Case  39.     G.  &  I).     March  24,   i<)04\.     T.   B.,  male,  aged 


358  Duodenal  Ulcer 

fifty-eight.  Stomach  symptoms  for  thirty  years.  Pain  and 
vomiting  after  food.  No  haematemesis.  Free  HC1  in  stomach 
contents  after  test-meal. 

Operation:  A  large  cicatrix  on  the  anterior  surface  of  the 
stomach  near  the  pylorus.  A  similar  scar  on  the  posterior 
surface  directly  opposite.  There  was  also  a  duodenal  scar. 
Posterior  gastroenterostomy.  Recovery.  Sent  by  Dr.  Nor- 
mington,  Nelson. 

Dr.  Normington  reports  June  22,  1905 :  "I  was  in  conversa- 
tion with  the  patient  on  Sunday  last.  The  result  of  the  opera- 
tion is  eminently  satisfactory.  He  eats  well  and  digests  his 
food.  Is  never  sick,  and  walks  with  an  alertness  at  one  time 
foreign  to  him.  He  has  largely  lost  his  cachectic  look.  He 
told  me  that  just  after  the  operation  he  felt  so  well  that  he 
overdid  eating,  but  that  so  long  as  he  exercises  ordinary  care 
he  has  nothing  to  fear.  He  thinks,  and  I  agree  with  him,  that 
the  operation  saved  his  life.  Splashing  in  stomach  does  not 
exist."  Dr.  Normington  writes,  July  2,  1908:  "Present  con- 
dition good.  Has  gained  weight;  now  stationary.  No  re- 
currence of  pain  nOr  vomiting.  Informs  me  that  he  is  better 
than  for  the  last  forty  years." 

Case  40. — (See  Case  24.)  D.  April  7,  1904.  T.  R.,  male, 
aged  thirty-one.  Patient  has  suffered  from  stomach  symp- 
toms since  January  19,  1902.  He  then  began  to  havQ  at- 
tacks of  pain  under  the  left  costal  margin.  These  became 
gradually  more  frequent,  but  were  never  accompanied  by 
vomiting.  Posterior  gastro-enterostomy  was  performed  June, 
1903, -for  duodenal  ulcer.  A  week  after  reaching  home  he 
began  to  vomit,  and  has  vomited  ever  since,  with  the  excep- 
tion of  a  few  intervals  of  about  a  week. 

Operation:  On  opening  the  abdomen  the  transverse  colon 
was  found  to  lie  very  low.  The  greater  part  of  the  small  in- 
testine,  all  but  the  last  18  inches,  had  herniated  through  the 
aperture  in  the  mesocolon  into  the  lesser  sac.  Adhesions  were 
separated  and  the  hernia  was  reduced.  The  gastro-enteros- 
tomy opening  admited  three  fingers,  but  a  loop  had  been  left 
between  the  flexure  and  the  stomach.  A  lateral  anastomosis 
was  effected  between  the  two  limbs  of  the  loop;  the  gut  was 
then   stitched   to  the  sides  of  the  opening  in  the  mesocolon 


Detailed  Statement  of  Cases  Operated  Upon  359 

to  prevent  a  recurrence  of  the  hernia.     Recovery.     He  was 
sent  by  Dr.  Crump,  Burnley. 

Seen  by  me  in  March,  1905.  Complained  of  great  weakness, 
but  could  eat  food  well.  I  advised  his  return  to  work.  Patient 
does  not  think  that  he  has  received  much  benefit  from  the 
operation,  but  he  is  now  able  to  work.  Suffers  from  ergo- 
phobia  and  neurasthenia. 

Dr.  Crump  writes  February  3,  1908:  "Has  indigestion  at 
times.  Present  weight,  8  stone;  stationary.  Has  pain  in 
attacks;  is  well  some  days,  and  on  other  days  has  pain. 
Lately  the  pain  has  been  under  the  left  ribs,  and  is  relieved 
by  bicarbonate  of  soda.  Has  had  attacks  of  vomiting  the 
last  four  months.  After  the  first  operation,  vomiting  on  his 
return  home  was  almost  daily;  brown  or  green  in  colour  and 
of  bitter  taste.  Says  he  feels  weak  and  has  sour  eructations. 
The  condition  of  the  patient,  who  is  a  neurotic,  has  improved 
considerably  since  the  last  operation,  but  he  has  always  been 
very  loath  to  admit  that  he  is  better.  He  has  been  able  to 
follow  his  employment  almost  continually  since  June,  1904." 

Case  41. — D.  June  17,  1904.  Mr.  H.,  aged  forty.  Has 
suffered  from  indigestion  for  twenty  years.  Flatulence  and 
pain  coming  on  one  to  one  and  one-half  hours  after  food. 
Twelve  months  ago  he  had  a  sudden  attack  of  faintness, 
followed  by  anaemia  and  great  general  feebleness.  He  noticed 
that  the  motions  were  black  for  some  days  after  the  attack. 
No  ha-matemesis.  Six  months  ago  a  recurrence  of  these 
symptoms;  commencing  dilatation  of  the  stomach  was  noticed 
by  Dr.  Trotter.  Two  similar  attacks  have  since  been  noticed; 
in  the  last  there  wras  "profuse  haemorrhage."  There  was 
copious  mehena  after  admission  to  the  hospital,  and  patienl 
fell  very  faint.  Great  tenderness  along  costal  margin  on 
righl   side  down  to  umbilicus.     Some  dilatation  of  stomach. 

Operation:    A  large  duodenal  ulcer,  about  i>.i  inch  beyond 

1  lie   pylorus,   with   much   thickening  and   opacity   around    it. 

Posterior  gastroenterostomy.     Recovery.     Scut    by   Dr.    R. 

1 1.  Trotter,  Holmfirth. 

Sen  by  me  June,   [905.    ('..lined  2  stone  in  weight.     Eats 

ordinals    diet  ;  absolutely    no  pain  nor  discomfort  of  any  kind. 

Says  he  is  quite  cured.     March,   io<>o:     His  brother  tells  me 


360  Duodenal  Ulcer 

he  is  quite  well.  Better  than  ever,  and  weighs  more  than  he 
has  ever  done. 

Dr.  Trotter  reports  January  29,  1908:  "In  good  health. 
Gain  after  operation  to  normal  weight,  which  is  12  stone. 
Now  weight  varies  little.  No  recurrence  of  pain  nor  vomiting. 
Is  perfectly  well  and  eats  anything." 

Case  42. — D.  July  16,  1904.  M.  R.,  female,  aged  twenty- 
six.  For  three  years  has  suffered  from  pain  in  the  epigastrium 
and  between  the  shoulders.  This  comes  on  immediately 
after  taking  food,  and  is  very  often  followed  by  vomiting, 
which  relieves  the  pain.  There  has  been  slight  haematemesis 
on  three  or  four  occasions. 

Operation:  Stomach  slightly  dilated,  cicatrix  on  the  ante- 
rior wall  of  the  first  part  of  the  duodenum, about  }/±  inch  beyond 
the  pylorus.  Posterior  gastroenterostomy.  Recovery.  Was 
sent  by  Dr.  Robb,  Accrington. 

Dr.  Robb  writes  in  June,  1905:  "She  has  been  'an  im- 
proved' since  the  operation.  She  has  put  on  flesh,  and  is 
physically  in  better  condition,  but  she  has  vomiting  at  times, 
and  occasionally  complains  of  pain  also."  No  further  report 
can  be  obtained. 

Case  43. — D.  August  4,  1904.  J.  C,  male,  aged  fifty- 
five.  Has  been  subjected  to  occasional  attacks  of  pain  for 
several  years.  Pain  rs  very  definitely  localised  over  the  upper 
part  of  the  right  rectus.  It  comes  on  at  night  and  lasts  two 
or  three  hours.  He  rarely  vomits.  Has  occasionally  been 
slightly  jaundiced.  While  in  hospital  he  passed  a  considerable 
quantity  of  altered  blood  per  rectum.  Is  very  thin,  anaemic, 
and  prematurely  aged. 

Operation:  A  mass  of  indurated  tissue  about  the  size  of  a 
hen's  egg  wras  found  involving  the  first  part  of  the  duodenum. 
It  was  considered  to  be  an  ulcer  with  surrounding  inflammatory 
thickening.  The  colon  wras  quite  blue  in  colour  from  con- 
tained blood.  Posterior  gastro-enterostom$\  Recovery. 
Sent  by  Dr.  Woods,  Killinghall. 

In  June,  1905,  he  was  reported  quite  well,  eating  ordinary 
food,  and  had  gained  2  stone   in  weight.     No  recent  report. 

Case  44. — D.  August  17,  1904.  A.  G.,  male,  aged  fifty- 
two.     Has  been  ailing  for  about  twelve  months  severely,  but 


Detailed  Statement  of  Cases  Operated  Upon  361 

slightly  for  nearly  three  years.  First  noticed  a  pain  in  the 
stomach  on  waking  at  2  or  3  o'clock  in  the  morning.  Would 
then  vomit  "nasty,  sour  stuff."  Pain  has  recently  increased 
very  much,  and  is  now  situated  to  the  right  of  the  middle  line, 
where  there  is  tenderness.  It  occurs  one  to  three  hours  after 
food,  and  is  accompanied  by  retching  and  foul  eructations. 
Has  had  several  attacks  of  severe  vomiting,  but  never  ha?mat- 
emesis.  The  stomach  is  large,  but  there  is  no  visible  peri- 
stalsis. 

Operation:  Duodenal  ulcer.  Many  adhesions  of  stomach. 
duodenum,  and.  omentum  to  anterior  abdominal  wall  high  up. 
Posterior  gastroenterostomy.  Adhesions  not  separated.  Re- 
covery. He  was  sent  by  Dr.  Xorman  Porritt  and  Sir  Wm. 
Broadbent. 

Report  received  from  Dr.  Porritt  June  21,  1905:  "Says 
he  thinks  the  operation  has  resulted  in  a  permanent  cure. 
Has  gained  flesh,  enjoys  food,  works  very  hard,  and  stomach 
symptoms  have  gone.  A  very  good  result."  Report  January 
29,  1908:  "Present  condition,  fairly  good  health;  gain  in 
weight,  about  16  lbs.  Has  had  no  pain  since  the  latter  part  of 
September.  1904,  and  only  when  on  the  sea.  The  operation 
has  been  successful." 

("ask  45. — D.  September  3,  1904.  Mrs.  M.,  aged  forty. 
Patient  was  confined  eleven  weeks  ago.  Three  weeks  after 
labour  began  to  feel  very  weak  and  languid,  and  one  day  she 
noticed  that  her  motions  were  quite  black;  they  continued  to 
be  so  for  eight  or  ten  days.  She  has  only  vomited  once. 
The  vomit,  according  to  her  doctor,  contained  about  one 
ounce  of  blood.  She  has  never  had  any  pain  in  the  abdomen. 
but  has  been  unable  to  take  solid  food  on  account  of  its  bring- 
ing on  palpitation.  There  was  constant  mehena  from  the 
time  of  admission  until  the  operation. 

Operation:  Stomach  a  little  dilated;  an  ulcer  in  the  first 
part  of  the  duodenum.  Posterior  gastro-enterostomy.  Re- 
covery.   She  was  -cut  by  Dr.  Lambert,  Farsley. 

Dr.  Lambert    reports  June  13,   I<)<),S:     "Although  somewhat 

anaemic,    has   had    no   recurrence   whatever  of   her   stomach 

symptoms.      Has   never  vomited   since   the  operation   and   has 

no  discomfort   after  food.     She  is  now   quite  well  and  doing 


362  Duodenal  Ulcer 

her  work."  Dr.  Lambert  reports  November  8,  1908:  "Saw 
patient  three  months  ago;  she  was  extremely  well,  and  has 
no  symptoms  referable  to  her  stomach." 

Case  46. — D.  September  13,  1904.  Mr.  L.,  aged  twenty- 
eight.  Was  operated  upon  by  me  four  years  ago  for  acute 
suppurative  appendicitis.  About  two  years  ago  began  to 
have  pain  about  two  or  three  hours  after  food.  Vomiting, 
no  hsematemesis,  frequent  melaena.  Is  profoundly  anemic; 
has  a  right  inguinal  hernia. 

Operation:  A  large  duodenal  ulcer  about  3^>  inch  beyond 
the  pylorus.  It  was  about  the  size  of  a  hazelnut,  very  dense, 
and  puckered  at  the  centre,  where  it  seemed  on  the  verge  of 
perforation.  Posterior  gastroenterostomy.  Radical  cure  of 
hernia.     Recovery.     Sent  by  Dr.  Hinings,  Leeds. 

Report:  In  January,  1905,  was  making  rapid  progress. 
Dr.  Hinings  reports  February,  1908:  "Health  good;  no 
symptoms  connected  with  digestive  organs;  colour  now 
normal.  Gain  of  about  8  or  9  lbs.  in  weight.  No  recurrence 
of  pain  nor  vomiting.  Patient  states  that  on  one  occasion 
a  few  months  after  operation  he  noticed  that  the  stools  were 
tarry,  but  never  since." 

Case  47. — D.  October  21,  1904.  Dr.  F.,  aged  thirty- 
three. 

Operation:  Large  ulcer,  about  I  inch  in  diameter  and  as' 
big  as  a  shelled  walnut,  about  3^  inch  beyond  the  pylorus. 
Posterior  gastroenterostomy.  Recovery.  He  was  seen  by 
Dr.  Eve,  Dr.  Crawford  Watson,  and  Sir  Lauder  Brunton. 
Weight  at  operation,  9  stone  10  lbs.;  March  6,  1905,  11  stone 
10^  lbs.  In  June,  1905,  suffered  from  some  pain  and  acidity, 
attributed  to  overwork  and  injudicious  diet.  W7ith  care  in 
diet,  pain  disappeared.  Weight,  11  stone  9  lbs.  Patient 
reports  February  22,  1908:  "Perfectly  well.  Since  opera- 
tion I  have  gained,  and  am  at  present  about  5  lbs.  heavier 
than  I  have  ever  been.  Overworked  myself  and  had  a  recur- 
rence of  pain  a  few  months  after  operation.  No  vomiting. 
Have  never  felt  better  in  my  life  as  regards  my  stomach.  In 
fact,  can  hardly  believe  I  have  ever  been  operated  upon. 
Eat  and  drink  anything  without  any  bad  effect." 

Case  48. — D.      November    11,    1904.     J.    B.,    male,   aged 


Detailed  Statement  of  Cases  Operated  Upon  363 

fifty-one.  Symptoms  for  eighteen  months.  At  first  "hunger 
pain"  late  in  the  afternoon,  eased  by  food.  Latterly  pain 
always  three  hours  after  food,  no  matter  whether  solid  or 
liquid;  much  flatulence  and  distension.  Recently  loss  of 
weight. 

Operation:  Small  ulcer  just  at  the  commencement  of  the 
duodenum.  Gastro-enterostomy.  Recovery.  Sent  by  Dr. 
Alderton,  Barnoldswick. 

Report  from  Dr.  Alderton  June  21,  1905:  "I  am  very 
pleased  to  tell  you  that  B.  is  in  the  best  of  health.  He  has 
never  felt  the. least  stomach  trouble  since  he  came  home. 
He  has  gained  considerably  in  weight,  but  has  not  got  his 
full  strength  yet.  One  may  say  he  is  completely  cured." 
Report  January  21,  1908:  "Perfectly  well;  has  gained  in 
weight." 

Case  49. — D.  November  19,  1904. ,  M.  B.,  female,  aged 
forty-nine.  Has  suffered  severely  from  stomach  trouble  for 
six  years.  Less  severely  for  two  years  before  that.  Began 
with  pain  an  hour  or  two  after  food.  Belching,  flatulence, 
and  distension.  Did  not  vomit  often  and  then  only  acid 
mucus.  Latterly  has  lived  on  milk;  has  lost  2  stone 
in  weight  during  the  last  few  months.  Stomach  is  dilated 
and  visibly  contracting. 

Operation:  Stomach  dilated  and  hypertrophied.  A  large 
ulcer  just  beyond  the  pylorus;  no  adhesions,  but  decided 
stenosis.  Posterior  gastro-enterostomy.  Recovery.  Sent 
by  Dr.  Pritchard,  Dewsbury. 

In  March,  1905,  was  very  well.  Taking  food  as  well  as 
ever  and  lost  weight  had  been  regained.  Dr.  Pritchard  reports 
February  17,  1908:  "Frequently  has  attacks  of  vomiting 
and  pains  in  the  abdomen.  Has  gained  weight  since  the 
operation.  The  vomited  matter  is  green,  bilious,  and  plenti- 
ful. Patient  considers  she  is  much  better  since  the  operation, 
but  says  she  is  not  cured."     (A  case  of  regurgitation.) 

Case  50. — D.  March  3,  1905.  J.  L.,  male,  aged  fifty. 
Eighteen  months'  history  of  pain  after  food,  to  .1  degree  which 
lias  entirely  incapacitated  him  for  weeks  together.  During 
lasl  tour  month-  pain,  vomiting,  and  greal  loss  of  weight. 

Operation:     A  duodenal   ulcer  the  size  of  lead-pencil  ju>t 


364  Duodenal  Ulcer 

beyond  pylorus.  Posterior  gastroenterostomy.  Closure  of 
pylorus.  Recovery.  Sent  by  Dr.  W.  H.  Thompson,  Brad- 
ford. 

Seen  in  December,  1905.  Quite  well;  had  suffered  a  good 
deal  from  constipation  and  flatulence.  Dr.  Thompson  reports, 
January  29,  1908:  "On  May  26,  1905,  an  attack  of  acute 
abdominal  pain  with  faecal  vomiting  and  great  distension 
of  the  abdomen.  August  17,  1905,  a  violent  attack  of  pain 
with  vomiting.  In  1906  and  1907  he  had  recurrent  attacks 
of  pain,  but  less  severe  in  character.  The  faecal  vomiting 
on  May  26,  1905,  has  not  recurred.  He  twice  had  definite 
signs  of  intestinal  obstruction,  which,  however,  cleared  up. 
No  other  symptoms  beyond  constipation.  These  attacks  of 
pain  were  very  severe,  beginning  in  region  of  wound  and 
spreading  across  whole  abdomen.  He  says  he  is  a  much 
better  man  than  he  was  before  his  operation  and  feels  quite 
young  again,  and  can  do  his  work  better  than  ever  he  could." 
Weight  on  March  25,  1905,  8  stone  11  lbs.;  January  29, 
1908,  9  stone  7^2  lbs.  Seen  by  us  on  March  14,  1908.  The 
attacks  of  pain  and  vomiting  were  apparently  due  to  appendix 
trouble. 

Case  51. — D.  March  3,  1905.  Mr.  H.,  aged  thirty-eight. 
A  year  ago  began  to  surfer  from  vomiting;  before  then  for  a 
few  months  had  had  pain  beginning  a  little  more  than  an 
hour  after  food.  For  the  last  few  months  has  had  pain  in 
the  early  hours  of  the  morning — generally  about  3  a.  m. — and 
also  in  afternoon.  Food  relieved  pain  for  an  hour  or  more. 
Has  had  both  haematemesis  and  melaena  recently.  Stomach 
is  dilated,  with  faint  waves  of  peristalsis. 

Operation:  An  enormous  ulcer  in  the  duodenum  with  the 
surrounding  thickening  making  a  lump  as  large  as  one's 
fist.  Posterior  gastroenterostomy.  Pylorus  closed  on  prox- 
imal side.  Recovery.  Sent  by  Dr.  Preston,  Morecambe. 
He  gained  \%  stone  in  four  weeks. 

Report  received  from  Dr.  Preston  June  22,  1905:  "The 
operation  has  been  eminently  successful.  He  has  gained  over 
2  stone  in  weight,  now  being  close  on  13  stone,  as  compared 
with  10^  stone  on  admission.  His  appetite  is  good;  no  class 
of  food  comes  amiss  to  him.     His  bowels,  which  were  much 


Detailed  Statement  of  Cases  Operated  Upon  365 

constipated,  and  necessitated  constant  use  of  enemata,  now 
act  regularly  and  without  any  stimulation,  medicinal  or  other- 
wise. In  a  word,  ha  says  it  is  a  treat  to  live  and  that  he  never 
felt  better."  Seen  September,  1907:  Absolutely  perfect 
result.  Report  March  3,  1908:  "In  splendid  health  ever 
since  operation." 

Case  52. — D.  March  3,  1905.  J.  McC,  male,  aged  forty- 
three.  A  chronic  dyspeptic,  much  worse  since  November. 
1904;  almost  constant  pain  and  vomiting.  Dilated  contract- 
ing stomach. 

Operation:  Duodenal  ulcer.  Posterior  gastroenterostomy. 
Closure  of  pylorus.  Recovery.  Sent  by  Dr.  Lee  Potter, 
Dewsbury. 

Report  received  from  Dr.  Potter  June,  1905:  "His  condi- 
tion on  June  2d  was  very  much  improved,  as  he  was  able  to 
eat  and  digest  an  ordinary  meal  of  meajt,  potatoes,  and  York- 
shire pudding.  Before  operation  his  condition  was  one  of 
almost  continuous  pain  and  vomiting.  He  could  not  retain 
even  peptonised  food,  and  had  to  have  rectal  feeding  as  the 
only  means  of  comfortable  nourishment."  In  1908  had  been 
lost  sight  of. 

CASE  53. — D.  May  17,  1905.  Miss  C,  aged  thirty-one. 
An  attack  of  pain  in  the  stomach  and  vomiting  eight  years 
ago.  Since  then  she  has  been  subject  to  pain  coming  on  an 
hour  after  meals,  and  a  feeling  of  nausea.  Has  lived  almost 
entirely  on  fluids  for  the  last  year.  Beginning  of  this  year  the 
pain  became  more  acute,  with  occasional  vomiting.  No 
haematemesis.     Tenderness  and  hyperesthesia  in  epigastrium. 

Operation:  Stomach  and  first  part  of  the  duodenum  dilated. 
A  few  adhesions  to  duodenum.  Posterior  gastroenterostomy. 
Infolding  of  pylorus.  Recovery.  Sent  by  Dr.  Christie- 
Wilson,  Doncaster.   . 

Report  January  13.  [908:  " General  health  good.  Patienl 
says  she  does  not  know  if  she  has  gained  weight,  but  I  am 
sure  she  has.  She  has  to  be  careful  in  her  diet,  and  has  no 
pain  when  she  sticks  to  ti^h.  chicken,  milk  puddings,  etc. 
(  ,m not  take  beef  or  mutton  with  comfort.  Has  only  vomited 
twice  since  operation.  Vomit  consisted oi  food  which  she  should 
not  have  taken.     I  think  the  resull  is  highly  satisfactory." 


366  Duodenal  Ulcer 

CASE  54. — D.  June  17,  1905.  A.  \\\,  male,  aged  thirty- 
four.  Six  years'  stomach  trouble.  Pain  two  or  three  hours 
after  food,  relieved  by  food.  Tenderness  and  soreness  in 
epigastrium  and  back. 

Operation:  Duodenal  ulcer.  Posterior  gastroenterostomy. 
Recovery.     Was  sent  by  Dr.  Alderton,  Barnoldswick. 

Report  from  Dr.  Alderton  January  27,  1908:  "Strength 
not  what  it  should  be;  can  do  about  six  hours'  work  comfort- 
ably; after  that  gets  jaded.  Weight  stationary.  Has  had 
recurrence  of  pain.  Pain  comes  on  in  pit  of  stomach  and  in 
back  when  he  gets  run  down;  at  other  times  perfectly  clear. 
Vomits  frequently,  very  acid,  very  little  food  mixed.  Suffers 
from  constipation  with  a  tendency  to  increase.  Feels  and  is 
much  better  than  prior  to  his  operation."     (See  Case  172.) 

Case  55. — D.  July  10,  1905.  Mr.  S.,  aged  fifty.  Has  had 
stomach  symptoms  for  rather  over  two  years,  which  he  de- 
scribes as  a  sense  of  weight  and  discomfort  referred  to  the 
epigastrium,  coming  on  after  meals.  He  also  complains  of 
a  pain  in  the  left  side  above  the  crest  of  the  ilium.  Has  a 
feeling  of  nausea  after  meals,  but  no  vomiting.  Considerable 
loss  of  weight.  No  definite  tenderness  nor  hyperesthesia. 
No  tumour  felt.  Test-meal,  faintly  acid;  no  free  HC1;  lactic 
acid  present;  very  numerous  long  bacilli  seen. 

Operation,  July  14th:  No  evidence  of  carcinoma.  Scar 
of  an  ulcer  on  the  anterior  surface  of  the  duodenum,  V£  inch 
beyond  pylorus.  Few  adhesions  to  posterior  surface  of  stomach 
near  pylorus.  Posterior  gastro-enterostomy.  Recovery. 
Was  sent  by  Dr.  Clements.  Died  in  autumn,  1907,  of  "per- 
nicious anaemia,"  symptoms  of  which  first  appeared  four 
months  before. 

CASE  56. — D.  August  18,  1905.  J.  B.,  male,  aged  fifty- 
five.  First  began  to  suffer  epigastric  pain  about  twelve  mon  1  hs 
ago.  Pain  comes  on  immediately  after  taking  food.  There 
is  frequent  nausea,  but  no  vomiting".  Several  times  he  has 
noticed  slime  and  blood  in  his  motions.  They  are  often  of  a 
dark  colour  and  sometimes  contain  "worms."  He  has  limited 
his  diet,  although  he  finds  that  it  makes  very  little  difference 
to  the  pain.  Stomach  dilated.  No  tumour  felt;  no  local 
tenderne— 


Detailed  Statement  of  Cases  Operated  Upon  367 

Operation:  A  small,  indurated  ulcer  on  under  surface  of 
duodenum,  just  beyond  pylorus.  An  enlarged  gland  on  greater 
curvature.  Posterior  gastroenterostomy;  infolding  of  ulcer. 
Recovery. 

On  August  26th:  "He  was  taking  a  full  diet,  and  had  no 
discomfort  after  food."  Sent  by  Dr.  Mathews,  Kirby  Lons- 
dale. Seen  recently:  "A  perfect  case,  not  a  trace  of  any 
trouble  now." 

Case  57. — D.  September  22,  1905.  Mr.  R.,  aged  thirty- 
nine.  Has  suffered  for  about  twelve  years  from  pain  in  the 
epigastrium,  which  comes  on  about  three  hours  after  food, 
and  continues  until  the  next  meal,  which  temporarily  relieves 
it.  Frequent  watery  eructations,  but  vomiting  of  food  in 
any  quantity  uncommon.  Haematemesis  on  one  occasion. 
Has  lately  been  relieved  by  bismuth,  and  except  when  tak- 
ing this  drug  has  never  noticed  his  stools  to  be  black.  Certain 
articles  of  food,  such  as  beef  and  potatoes,  are  especially 
liable  to  excite  pain.  Constipation.  Stomach  dilated;  ten- 
derness in  upper  part  of  epigastrium  on  left  side.  Test-meal 
contains  free  HC1. 

Operation:  Stomach  dilated.  Scarring  and  kinking  of 
duodenum  just  beyond  pylorus;  first  part  of  duodenum 
dilated;  another  kink  in  its  second  part.  Posterior  gastro- 
enterostomy. Recovery.  Sent  by  Dr.  Ross,  Scarborough. 
There  was  a  slight  attack  of  pleurisy  during  the  first  week 
after  operation..  Report  December,  1907:  " Perfect ly  suc- 
cessful." 

Cask  58. — G.  &  D.  September  26,  1905.  A.  B.,  female, 
aged  thirty-nine.  Began  to  suffer  from  indigestion  eighl 
years  ago.  Three  years  ago  pain  was  constantly  noticed  aboul 
three  to  four  hours  after  food,  relieved1  by  nexl  meal.  Vomit- 
ing at  first  was  infrequent,  but  latterh  has  been  noticed  at 
leasl  two  or  three  times  a  week  in  large  quantities.  She 
has  cold,  livid  extremities,  and  quite  characteristic  tetany. 
Stomach  enormous;  waves  of  contraction  seen  at  all  times. 

operation:  Stomach  much  enlarged  and  greatly  hyper- 
trophied.  A  hard,  puckered  lump  was  found,  beginning  on 
the  stomach  side  of  the  pylorus,  and  extending  about  '  •_>  inch 
into  1  he  (hidden  11  m.  Posterior  gastro-enterostomy.  Recovery. 
Was  -cut  l>\   Dr.  Charles  Richardson,  Leeds. 


368  Duodenal  Ulcer 

Report  January,  1908:  "2^  stone  gained.  Quite  com- 
fortable and  delighted  with  the  result." 

Cask  59. — G.  &  D.  August  27,  1905.  Mr.  E.  Has  suffered 
from  stomach  troubles  for  a  long  time,  but  was  fairly  well 
until  five  months  ago.  Then  began  to  suffer  from  pain  about 
three  hours  after  food.  Sour  eructations,  distension,  and 
every  two  or  three  days  copious  vomiting.  The  motions 
are  at  times  black,  but  he  has  had  no  fainting  attacks.  The 
vomit  was  blood-streaked  on  one  occasion.  Stomach  greatly 
dilated  and  contracting;  epigastric  tenderness. 

Operation:  Stomach  greatly  dilated  and  hypertrophied. 
A  thickening  was  felt  on  the  anterior  surface  near  the  lesser 
curvature,  covered  writh  injected  roughened  peritoneum  and 
some  recent  adhesions.  First  part  of  duodenum  dilated. 
Induration  felt  at  the  junction  of  first  and  second  parts  of 
duodenum,  which  was  drawn  firmly  back  to  posterior  abdomi- 
nal wall.  Posterior  gastro-enterostomy.  Recovery.  Sent  by 
Dr.  Ellis,  Halifax. 

Report  from  Dr.  Ellis  January,  1908:  "Perfectly  well. 
Has  asthma  at  times  and  would  like  gastro-enterostomy  done 
on  his  lungs." 

Case  60. — D.  November  14,  1905.  W.  K.,  male,  aged 
thirty-one.  For  the  last  two  years  has  suffered  occasionally 
from  pain  along  the  right  costal  arch  as  far  as  the  middle  line, 
coming  on  three  to  six  hours  after  meals.  Latterly  this  has 
been  more  severe  and  he  has  lived  entirely  on  fluids.  After 
taking  a  meal  he  feels  comfortable  for  about  a  couple  of  hours; 
is  then  distended  and  flatulent,  and  belches  sour  fluid.  About 
four  hours  after  food  pain  comes  on  and  increases  in  severity. 
It  is  relieved  for  a  time,  however,  by  taking  more  food.  Has 
lost  Y2  stone  in  weight.     No  dilatation  nor  stasis. 

Operation:  A  circular  ulcer,  hard  and  with  puckered  centre, 
the  size  of  a  threepenny  piece,  just  beyond  the  pylorus. 
Posterior  gastro-enterostomy.     Infolding  of  ulcer.     Recovery. 

Report  January,  1906:  "Quite  well."  Report  January, 
[908:     "Quite  well." 

Case  61. — D.  December  8,  1905.  Mr.  S.  Nine  years 
ago  suffered  from  pain  one  hour  after  food;  this  lasted  for 
about   two   years.     Since   then   he   has  been  well   until   eight 


Detailed  Statement  of  Cases  Operated  Upon  369 

months  ago.  Since  then  the  pain  has  returned.  It  is  more 
or  less  continuous  and  at  times  severe.  Occasional  slight 
sickness;  no  haematemesis.  Loss  of  weight,  3^2  stone.  Stomach 
not  much  dilated;  peristalsis  seen  on  inflation.  Tenderness 
and   rigidity  in  right  hypochondrium;  no  tumour  palpable. 

Operation:  Stomach  large;  adhesions  between  duodenum 
and  under  surface  of  liver  and  gall-bladder;  these  were  so 
dense  as  to  suggest  the  possibility  of  a  cysto-duodenal  fistula. 
No  stones  felt  in  gall-bladder  nor  ducts.  Posterior  gastro- 
enterostomy.   Recovery.    Sent  by  Dr.  Shine. 

Report  January,  1908:    "As  good  a  result  as  I  could  wish." 

Case  62. — D."  December  8,  1905.  Mr.  E.  Symptoms 
were  those  of  "hunger  pain,"  etc. 

Operation:  A  chronic  ulcer  beyond  the  pylorus,  with 
induration  and  stenosis.  Some  swollen  glands  on  lesser 
curvature.  Not  much  gastric  dilatation.  Posterior  gastro- 
enterostomy.    Recovery.     Sent  by  Dr.  Arnley,  Stainland. 

Report  January,  1908:     "Going  on  well." 

Case  63. — D.  December  11,  1905.  Miss  C,  aged  twenty- 
seven.  An  attack  of  vomiting  five  years  ago.  Since  then  she 
has  suffered  from  occasional  indigestion.  One  month  ago 
another  attack  of  vomiting  and  pain.  The  vomiting  occurred 
directly  after  taking  food ;  on  a  restricted  diet  it  has  been 
better,  but  the  pain  continues  on  the  right  side  of  epigastrium 
and  is  uninfluenced  by  meals.  No  haematemesis.  Loss  of 
weight.  Stomach  on  inflation  reaches  to  umbilicus;  great 
tenderness  and  hyperesthesia  to  right  of  navel.  After  twelve 
In  Hits'  fast,  no  HC1  and  no  evidence  of  stasis. 

Operation:  Stomach  and  first  part  of  duodenum  slightly 
dilated.  Delicate  scar  and  induration  on  anterior  surface 
of  duodenum,  just  beyond  pylorus.  Adhesions  stretching 
across  duodenum  to  right  lobe  of  liver.  Posterior  gastro- 
enterostomy. Infolding  of  pylorus.  Recovery.  Sent  by 
Dr.  Hinde. 

In  January,  1908,  was  reported  "quite  well." 

Case  64.     G.  &  D.     December   15.   1905.     Mr.  \Y..  aged 
sixty-four.     Has  had  a  sense  of  weighl  and  heaviness  in  the 
epigastrium  after  meals  for  mam   years,  bul  n«>  severe  pain. 
Has  been  worse  during  the  la^i  twelve  months  .m<l  occasion 
24 


370  .  Duodenal  Ulcer 

ally  vomits  a  small  quantity  of  watery  fluid.  No  hsematemesis. 
Marked  loss  of  weight  and  appetite.  Stomach  on  inflation 
reaches  to  within  one  inch  of  umbilicus.  Peristalsis  visible. 
Stomach  empty  after  fourteen  hours'  fast. 

Operation:  Stomach  not  dilated;  thickening  of  ulcer  in 
anterior  wall  of  duodenum  just  beyond  pylorus,  which  did 
not  appear  narrowed.  Tough  adhesion  to  posterior  stomach 
wall.  Posterior  gastro-enterostomy  and  infolding  of  pylorus. 
Recovery.  Sent  by  Dr.  McCully.  Improved  slowly  at  first, 
but  came  in  November,  1907,  to  express  his  delight. 

Case  65. — D.  December  20,  1905.  Miss  S.,  aged  thirty- 
seven.  Stomach  troubles  for  at  least  ten  years.  Pain  across 
the  upper  abdomen  some  time  after  food.  Often  relieved  by 
food.  No  vomiting.  Lives  chiefly  on  fluids.  Loss  of  weight. 
An  enormous  stomach  on  inflation;  faint  visible  peristalsis. 

Operation:  An  ulcer  in  the  first  part  of  the  duodenum  with 
induration.  Posterior  gastro-enterostomy;  infolding  of  py- 
lorus.    Recovery.     Sent  by  Dr.  Hebblethwaite,  Keighley. 

Report  January,  1908:     "In  splendid  health." 

Case  66. — D.  January  13,  1906.  Mrs.  F.  Indigestion 
for  the  last  ten  months.  Pain  in  the  lower  sternal  region 
immediately  after  food,  gradually  diminishing  in  intensity, 
but  leaving  a  dull  ache  which  is  almost  continuous.  Occasional 
vomiting;  no  haematemesis.  For  some  months  she  has  con- 
fined herself  to  a  liquid  diet  and  vomiting  has  been  less. 
On  two  previous  occasions  she  has  had  somewhat  similar 
symptoms  for  periods  of  about  three  months.  Loss  of  weight. 
Abdomen  lax;  stomach  hangs  low,  but  is  little,  if  at  all, 
dilated.  Marked  tenderness  and  hyperesthesia  in  epigas- 
trium; no  evidence  of  stasis. 

Operation:  Recent  adhesions  between  duodenum  and  gall- 
bladder; no  ulcer  palpable.  Stomach  hangs  low  and  is  slightly 
dilated.  Posterior  gastro-enterostomy.  Recovery.  Sent  by 
Dr.  Goode,  Doncaster. 

Report  November,  1908:  "Patient  looks  much  better  and 
stronger.  Has  gained  a  stone  and  a  half.  Very  occasionally 
has  pain  and  vomiting  after  a  too  hearty  meal.  I  consider 
this  case  a  remarkably  good  result." 

Case  67. — D.     February  8,    1906.     Mr.   K.,   aged  forty. 


Detailed  Statement  of  Cases  Operated  Upon  371 

First  taken  ill  about  five  years  ago  with  pain  across  upper 
abdomen  and  black  stools.  This  lasted  about  fourteen  days. 
Somewhat  similar  attacks  have  since  occurred  at  intervals  of 
one  to  two  years,  though  latterly  they  have  become  more 
frequent.  During  these  attacks  he  has  pain  across  the  epi- 
gastrium, passing  round  to  the  back  and  occurring  some  time 
before  a  meal  is  due.  The  stools  become  black;  there  is 
vomiting  at  intervals  of  a  few  days,  but  never  in  large  quan- 
tities. Thinks  he  has  vomited  blood.  The  attacks  are  gen- 
erally relieved  by  liquid  diet  and  rest.  Stomach  dilated; 
no  visible  peristalsis. 

Operation:  Stomach  large;  a  firm,  cartilaginous  indura- 
tion at  the  junction  of  the  first  and  second  parts  of  the  duo- 
denum, which  was  bound  down  to  the  posterior  abdominal 
wall.  Posterior  gastroenterostomy;  infolding  of  pylorus. 
Recovery.    Sent  by  Drs.  Muir  and  Haigh. 

Report  March,  1009:  Is  perfectly  well;  has  gained  28 
lbs.  Could  never  take  solid  food  without  pain  before  opera- 
tion and  always  looked  anaemic.  Now  can  take  any  kind  of 
food  and  looks  rosy  and  in  perfect  health.  Has  required  no 
medical  attendance  since  operation. 

(  \se  68. — G.  &  D.  January  24,  1906.  Mr.  F.,  aged  fifty- 
five.  Suffered  from  flatulent  distension  for  years.  During 
the  last  nine  months  has  had  heartburn  and  pain  two  to  four 
hours  after  food.  Food  generally  relieves.  Pain  in  the 
abdomen  radiates  to  the  left  breast  and  side.  Lately,  it  has 
always  come  "when  he  wants  something  to  eat  again."  lla^ 
lost  2  stone  in  three  months.  Stomach  before  inflation  an 
inch  above  umbilicus;  after  inflation,  2^  inches  below. 

Operation:  Stomach  large  and  a  little  hypertrophied.  A 
large  ulcer  the  size  of  a  walnut  in  first  part  of  duodenum. 
Ulceration  on  the  lesser  curvature  with  adhesions  to  under 
surface  of  liver  and  diaphragm.  Posterior  gastroenteros- 
tomy. (Insure  of  pylorus.  Recovery.  Scut  by  Dr.  Veale, 
I  )righlington. 

On  July  10th:  Gained  2  stone  8  lbs.  Eats  anything; 
better  than  for  years.  Report  March,  i<)<><):  Is  fat,  robust, 
and  healthy;  no  pain;  has  gained  weight.  Says  he  feels  better 
t •  ><  1 . 1  >   than  for  thirteen  <»r  fourteen  year 


372  Duodenal  Ulcer 

Case  69.— D.  February  2,  1906.  Mr.  H.,  aged  thirty- 
eight.  Has  had  stomach  trouble  more  or  less  all  his  life. 
Now  complains  chiefly  of  pain  and  fullness  coming  on  about 
one  or  two  hours  after  food.  Vomits  frequently  and  copiously. 
Can  take  all  foods,  but  solids  cause  great  distension,  dis- 
comfort, and  irritation.  Has  lost  1%  stone.  A  large  wavy 
stomach. 

Operation:  A  large  chronic  ulcer  beyond  the  pylorus,  with 
many  adhesions  to  surrounding  parts.  Posterior  gastro- 
enterostomy. Infolding  of  ulcer.  Recovery.  Sent  by  Dr. 
Mathews,   Holmfirth. 

Report  July  28th:  "Could  eat  all  right;  no  pain  or  dis- 
comfort." Dr.  Mathews  reports,  November,  1908:  "No 
recurrence  of  pain  nor  vomiting.  This  patient  has  left  the 
district,  but  when  I  saw  him  last,  about  six  months  ago,  he 
was  in  distinctly  high  spirits  about  himself." 

Case  70. — G.  &  D.  March  4,  1906.  Mr.  S.,  aged  twenty- 
one.  Has  suffered  from  indigestion  for  about  three  years, 
chief  symptoms  being  pain  after  food,  usually  four  or  five 
hours  after  a  meal,  though  latterly  has  also  had  a  pain  half 
an  hour  after.  Vomiting  commenced  five  months  ago;  it 
often  occurs  several  times  a  day,  and  then  there  may  be  a  few 
days'  interval.  Vomit  small  in  amount  and  has  never  con- 
tained blood.  No  melacna.  Stomach  dilated;  reaches  below 
umbilicus;  no  visible  peristalsis.  Some  tenderness  to  the  left 
of   umbilicus. 

Operation:  Well-marked  ulcer  in  the  first  part  of  the  duo- 
denum. Some  enlarged  glands  along  both  curvatures.  A 
second  ulcer,  surrounded  by  considerable  induration,  on 
lesser  curvature  towards  cardia.  Posterior  gastroenteros- 
tomy. Infolding  of  gastric  ulcer  and  pylorus.  Recovery. 
Sent  by  Dr.  Mitchell,  Houten-Pagnell. 

Report  November,  1908:  In  good  health.  Weighed  7 
-tone  9  lbs.  after  operation;  11  stone  about  one  year  after- 
wards; now  weighs  9  stone  10  lbs.  Has  occasional  slight  pain 
alter  a  hearty  meal.  There  is  some  vomiting;  it  occurs  about 
once  a  fortnight,  and  occasionally  lasts  two  or  three  days. 
Vomit  sour  and  contains  little  food.  Vomiting  is  not  nearly 
so  bad  as  it  was  soon  after  the  operation.     He  feels  much 


Detailed  Statement  of  Cases  Operated  Upon  373 

better  than  he  did  before,  and  he  never  feels  the  same  pain 
as  he  had  suffered  from  for  years. 

Case  71. — D.  May  16,  1906.  Mr.  D.,  aged  forty-four. 
Epigastric  pain  for  many  months,  felt  most  acutely  during 
the  night.  He  wakes  up  at  12  to  1  o'clock  with  severe,  cramp- 
like pains.  If  pain  occurs  in  the  daytime,  as  it  has  done 
recently,  it  comes  two  or  three  hours  after  a  meal.  Has 
occasionally  felt  great  relief  by  taking  food.  Has  had  melaena 
and  several  acute  attacks  of  vomiting.  Stomach  not  dilated. 
A  very  tender  point  just  above  umbilicus. 

Operation:  A  very  large  ulcer  at  junction  of  first  and  second 
portion  of  duodenum.  Posterior  gastroenterostomy.  In- 
folding of  the  ulcer,  causing  closure  of  the  duodenum.  Re- 
covery.    Sent  by  Dr.  Cowan  Hamilton,  Lancaster. 

Report  November,  1908:  Health  very  good;  gained  about 
20  lbs.;  no  pain  nor  vomiting;  not  the  slightest  symptoms  of 
trouble.  Dr.  Cowan  Hamilton  says:  "He  has  regained  his 
massive  weight.  He  is  the  picture  of  health,  and  he  and  I 
are  deeply  grateful." 

(ask  72. — D.  May  16,  1906.  Mr.  P.,  aged  fifty-three. 
Began  to  suffer  from  dyspepsia  eighteen  months  ago.  Pain 
one  hour  after  food,  relieved  by  food  for  about  an  hour. 
Vomiting,  haematemesis,  and  melaena.  Ten  months  ago 
severe  attack  in  which  he  fainted. 

Operation:  A  very  large  duodenal  scar  on  anterior  surface 
just  beyond  the  pylorus.  It  formed  a  hard,  indurated  lump 
as  big  as  a  walnut.  Posterior  gastroenterostomy.  Recovery. 
Sent   by   Dr.   Holliday,   Cildersome. 

Report  from  Dr.  Holliday  November,  1908:  "In  very 
I  health;  is  back  to  his  normal  weight;  says  that  he  has 
not  fell  anything  since  the  operation." 

Case  73.  G.  &  1).  June  20.  [906.  Mr.  H.,  aged  thirty- 
five.  Had  1  rouble  with  hi>  stomach  twelve  years  ago.  Ai 
the  onsel  a  sudden  attack  of  pain,  collapse,  and  vomiting. 
Now   has  pain   constantly  one   to   two  hours  after  a   meal, 

ed  by  taking  food.  Vomits  occasionally  and  is  always 
relieved  thereby.    A  dilated  stomach  with  fainl  waves. 

Operation:  Much  thickening  over  the  firs!  part  oi  the 
duodenum;  stomach  dilated  with  -cars  on  it-  anterior  surf; 


374  Duodenal  Ulcer 

Jejunum  bound  by  adhesions  to  posterior  abdominal  wall. 
These  were  divided  and  posterior  gastro-enterostomy  was 
performed.  Recovery.  Sent  by  Dr.  Pritchard,  Dewsbury. 
This  patient  cannot  be  traced. 

Case  74. — D.  June  29,  1906.  Mr.  M.,  aged  sixty.  Has 
been  vomiting  more  or  less  for  twenty  years.  At  first  it 
occurred  only  occasionally,  two  or  three  hours  after  food. 
Gradually  became  more  severe,  until  it  occurred  within  about 
an  hour  after  every  meal.  Some  epigastric  pain,  which  is 
relieved  by  vomiting.  Occasional  hsematemesis  and  "dark 
stools."     Stomach  dilated. 

Operation:  First  part  of  the  duodenum  found  dilated  and 
thickened.  Posterior  gastro-enterostomy  by  Mayo's  method. 
Infolding  of  pylorus.     Sent  by  Dr.  Dimmock,  Harrogate. 

Report  July  13,  1906:  "Has  been  vomiting  about  once  a 
day  since  operation."  In  October  reported  to  be  much  better. 
Report  September,  1909:  "I  find  M.  has  gained  a  certain 
amount  of  strength.  He  still  has  vomiting  attacks  at  intervals 
of  three  or  four  weeks,  when  he  uses  the  stomach-tube  for  lav- 
age, but  at  no  other  time.  Sleeps  well  and  is  following  his  occu- 
pation as  a  painter,  only  having  to  desist  from  work  during  the 
attack,  about  every  month,  and  that  onty  for  a  day  or  two." 

Case  75. — D.  June  29,  1906.  B.  B.,  female,  aged  twenty- 
seven.  Suffers  greatly  from  abdominal  pain,  especially  after 
food,  but  occurring  at  no  regular  interval  after  the  meal. 
Vomits  frequently  and  induces  vomiting  to  relieve  pain. 
Rest  in  bed  for  eight  weeks  has  led  to  no  improvement;  no 
free  HO.     Lactic  acid  present. 

Operation:  Adhesions  between  under  surface  of  liver  and 
pylorus  and  duodenum.  Many  adhesions  around  appendix. 
Posterior  gastro-enterostomy.  Appendicectomy.  Recovery. 
Sent  by  Dr.  Adams,  Sowerby  Bridge. 

Report  from  Dr.  Adams  November,  1908:  "On  the  whole, 
better.  Able  to  walk  about  more  and  does  not  spend  so 
much  time  in  bed.  No  difference  in  weight.  There  is  occa- 
sional pain  and  vomiting,  but  much  less  frequent  than  before 
operation.  I  consider  the  case  is  better  than  she  has  been 
for  years.  There  is  no  doubt  a  considerable  neurotic  element 
present." 


Detailed  Statement  of  Cases  Operated  Upon  375 

Case  76. — D.  July  25,  1906.  Mr.  W.,  aged  thirty-eight. 
Indigestion  for  years.  Two  years  ago  this  became  much 
worse  and  haematemesis  and  melaena  occurred.  A  second 
attack,  chiefly  melaena,  in  April  of  this  year.  Pain  usually 
three  hours  after  a  meal,  "when  he  gets  hungry."  Pain  is 
always  eased  by  food,  so  that  he  always  carries  a  biscuit  in 
his  pocket.  Since  May  he  has  been  perfectly  well,  but  fears 
recurrence. 

Operation:  A  circular  hard  ulcer  found  about  %  inch 
beyond  pylorus,  on  anterior  surface  of  duodenum ;  few  omental 
adhesions.  Posterior  gastroenterostomy.  Infolding  of  ulcer. 
Recovery.    Sent  by  Dr.  Galloway,  Otley. 

Report  July,  1909:  "Much  better  than  before  operation, 
but  says  he  is  never  quite  free  from  discomfort.  This  dis- 
comfort is  mainly  attributable  to  flatulence.  Takes  ordinary 
food.  Is  not  so  pale  as  he  used  to  be  and  looks  very  much 
better." 

Case  77. — G.  &  D.  August  7,  1906.  E.  H.,  female,  aged 
forty.  Stomach  trouble  commenced  three  years  ago.  Pain 
soon  after  food  at  first;  later  occurred  some  time  after  food, 
and  was  relieved  by  a  meal;  finally  began  to  occur  irrespective 
of  food  and  was  almost  continuous.  Quite  recently  has  taken 
solid  food  fairly  well,  but  has  fullness  and  heaviness  after  it. 
Occasional  vomiting,  which  relieves  the  distress.  A  visibly 
contracting  stomach. 

Operation:  A  tight  stenosis  with  evidence  of  old  ulceration 
and  adhesions  in  first  part  of  duodenum  and  along  adjacent 
parts  of  lesser  curvature.  Posterior  gastroenterostomy. 
Recovery. 

Report    November,  1908:     "The  old  pain  which  I  suffered' 
from  so  long  is  quite  a  thing  of  the  past.     Fur  years  I   was 
never  so  well,  and  all  my  lift'  shall  feel  grateful." 

Case  78. — D.  August  21.  [906.  Miss  T..  aged  forty- 
nine.  Indigestion  and  vomiting  aboul  fifteen  years  ago. 
Ever  since  then  -he  has  been  liable  to  attacks  of  epigastric 
discomfort.  Haematemesis  and  fainting  t\\<>  years  ago.  A 
second  attack  with  melaena  four  months  ago.  She  r.uvK 
vomits,  bul  regurgitates  a  little  fluid  into  the  mouth.  The 
abdominal  discomforl  is  fell  aboul  a  quarter  of  an  hour  after 


376  Duodenal  Ulcer 

a  meal.  A  stout  woman  with  a  prominent  epigastrium. 
Stomach  not  dilated.  Tender  above  umbilicus,  especially 
towards   right   costal   margin. 

Operation:  Puckering  of  ulcer  on  anterior  wall  of  duodenum 
immediately  beyond  pylorus.  Gall-bladder  distended  and 
containing  a  stone  in  its  pelvis.  Posterior  gastroenterostomy. 
Infolding  of  ulcer.  Cholecystostomy.  Recovery.  Sent  by 
Dr.  Jalland,  York. 

Report  from  Dr.  Jalland  November,  1908:  "Present  con- 
dition very  good;  gain  in  weight;  slight  flatulent  discomfort 
after  meals.  Has  vomited  occasionally,  but  this  has  been 
generally  due  to  having  taken  lemon  in  some  form.  Looks 
the  picture  of  good  health,  and  goes  about  doing  every- 
thing as  usual." 

Case  79. — D.  September  19,  1906.  J.  A.  I.,  female, 
aged  thirty-nine.  Two  and  one-half  years  ago  she  began  to 
suffer  a  dull  aching  pain  in  the  epigastrium,  not  severe,  and 
generally  wTith  no  apparent  relation  to  food.  Food  and  hot 
drinks,  however,  usually  relieved  it.  No  vomiting.  These 
attacks  came  on  about  every  three  days.  For  the  past  six 
months  pain  more  severe  and  more  frequent.  Vomited  for 
the  first  and  only  time  a  month  ago.  No  blood.  Loss  of 
weight.  Stomach  not  much  enlarged;  slight  visible  peri- 
stalsis. 

Operation:  An  ulcer  in  duodenum  close  to  pylorus.  Pos- 
terior gastroenterostomy.  Recovery.  Sent  by  Dr.  Cass, 
Ravenglass. 

Dr.  Cass  reports  November,  1908:  "Present  condition 
very  satisfactory.  Has  occasional  pain  if  overworked;  diets 
herself  carefully.  On  the  whole,  has  very  good  health;  the 
only  symptom  that  troubles  her  is  the  above-mentioned  pain, 
which  is  usually  due  to  errors  of  diet  or  overwork." 

Case  80. — D.  September  20,  1906.  Mr.  P.,  aged  sixty- 
one.  Suffered  from  indigestion  for  the  last  two  years.  Pain 
usually  occurs  about  three  hours  after  food.  It  is  felt  as  a 
girdle  extending  across  the  epigastrium  and  round  to  the 
back.  When  the  pain  is  at  its  greatest,  the  skin  enclosed 
in  this  girdle  is  extremely  sensitive,  even  contact  with  the 
bedclothes  being  unendurable.     Pain  is  immediately  relieved 


Detailed  Statement  of  Cases  Operated  Upon  377 

by  vomiting.  Formerly  this  was  self-induced,  but  for  the 
last  three  months  it  has  occurred  spontaneously  about  once 
a  week.  Vomit  is  small  in  quantity  and  does  not  contain 
blood.  Melgena  has  never  been  noticed.  Appetite  good,  but 
he  has  lost  2  stone  in  weight  in  the  last  three  months. 
Stomach  dilated;  some  tenderness  just  above  umbilicus. 

Operation:  Stomach  dilated;  no  adhesions.  Well-marked 
scar  of  an  ulcer  on  anterior  wall  of  duodenum  half  an  inch 
beyond  the  pylorus.  A  calculus  was  felt  in  the  pelvis  of  the 
gall-bladder.  Posterior  gastroenterostomy.  Infolding  of 
ulcer.  Owing. to  the  condition  of  the  patient  it  was  not 
thought  wise  to  prolong  the  operation  in  order  to  remove  the 
gall-stone.     Recovery.    Sent  by  Dr.  J.  J.  Anning,  Beeston. 

During  convalescence  from  operation  an  acute  attack  of 
pain  in  epigastrium,  with  much  flatulence,  which  was  relieved 
by  vomiting.  During  the  next  two  years  suffered  from  fre- 
quent attacks  of  severe  epigastric  pain,  which  always  occurred 
soon  after  a  meal,  and  were  accompanied  by  distressing 
flatulence.  Pain  usually  lasted  a  few  hours,  and  was  relieved 
by  the  induction  of  vomiting  and  occasionally  by  morphia. 
On  October  28,  1908,  the  abdomen  was  again  opened.  Gall- 
bladder was  found  to  be  hour-glass  in  shape  and  to  contain 
several  stones  in  both  compartments.  Cholecystectomy. 
The  scar  of  the  old  duodenal  ulcer  was  seen  and  infolded. 
No  evidence  of  any  persisting  ulceration. 

Report  June,  1909:  "Patient  is  free  from  pain  and  has 
gained  in  weight,  and  is,  on  the  whole,  in  very  good  health. 
A  biliary  fistula  persisted  for  a  considerable  time,  bu1  has 
now   closed." 

Case  81. — D.  September  25,  [906.  Mr.  D.,  aged  thirty- 
eight.  Suffered  from  his  stomach  for  the  lasl  three  years. 
Attacks  of  pain  and  vomiting  lasting  from  two  to  three 
weeks  to  over  a  month.  Between  these  attacks  he  can  take 
ordinary  food,  but  during  them  he  confines  himself  to  milk 
diet.  Pain  has  no  very  definite  relation  to  taking  food.  It 
is  fell  mosl  severely  about  the  ensiform  cartilage,  thence 
passing  downwards  along  each  costal  margin.  Vomiting 
gives  immediate  relief  t<>  pain.  Has  losl  weighl  considerably. 
Abdomen  was  explored   two  years  ago  bj    another  surgeon, 


378  Duodenal  Ulcer 

but  nothing  further  was  done.  Epigastrium  very  tender;  on 
inflation  the  stomach  bulges  to  the  left. 

Operation:  Omental  adhesions  to  the  old  scar;  stomach  not 
dilated;  the  duodenum  entered  a  mass  of  adhesions  near  the 
cystic  duct.  ■  These  were  separated  and  a  fistula  between 
duodenum  and  gall-bladder  demonstrated.  The  ascending 
part  of  the  duodenum  was  found  to  lie  on  the  middle  line, 
overlapping  the  aorta.  Posterior  gastroenterostomy,  with 
vertical  stoma.     Sent  by  Dr.  Johnston,  Ilkley. 

Report  from  patient  November,  1908:  "My  health  is 
very  good."     No  further  report  can  be  obtained. 

Case  82. — D.  September  26,  1908.  Mr.  R.,  aged  twenty- 
three.  Subject  to  indigestion  for  the  last  six  or  seven  years. 
For  the  first  two  years  of  this  period  used  to  suffer  epigastric 
pain  fairly  regularly  about  11  a.m.  and  4  P.  M.  Now  the 
pain  is  less  regular  in  onset,  but  more  constant.  The  pain  is 
felt  about  the  centre  of  the  epigastrium  and  passes  through 
to  the  back.  Careful  dieting  relieves  these  symptoms  for  a 
time;  then  another  attack  will  be  brought  on  by  a  return  to 
ordinary  food.  Six  weeks  ago  had  an  attack  of  vomiting — 
the  only  one.     Stomach  rather  dilated;  no  tenderness. 

Operation:  About  24  inch  beyond  the  pylorus  the  duodenum 
was  narrowed  by  the  puckered  scar  of  an  ulcer  on  its  anterior 
wall.  Posterior  gastroenterostomy.  Infolding  of  ulcer. 
Recovery.     Sent  by  Dr.  Bertram  Watson,  Harrogate. 

Report  November,  1908:  "Am  sound  in  every  way. 
\<  >  symptoms  which  have  given  me  the  least  anxiety.  A  gain 
of  about  1 3^2  stone  in  weight,  characterised  by  a  remarkably 
steady  progress.  I  do  not  particularise  in  regard  to  diet, 
although  on  principle  I  refrain  from  such  things  as  are  com- 
monly known  as  indigestible.  A  year  ago  I  was  accepted  by 
a  leading  insurance  office  as  a  first-class  life  on  the  lowest 
terms,  the  history  of  my  illness  and  operation  having  been 
fully  considered  by  the  medical  officers." 

Case  83.— G.  &  D.  October  7,  1906.  Mr.  S.  Many 
attacks  of  gall-stone  colic  since  1897.  Pain  varies  much  in 
severity  and  is  sometimes  followed  by  jaundice. 

Operation:  Gall-bladder  contains  many  small  calculi; 
contracted  scar  of  ulcer  on  anterior  duodenal  wall.     One  or 


Detailed  Statement  of  Cases  Operated  Upon  379 

two  dense  white  scars  on  posterior  wall  of  stomach.  Posterior 
gastroenterostomy.  Cholecystostomy.  Recovery.  Sent  by 
Dr.   Harbinson. 

In  June,  1909,  was  readmitted  to  the  Nursing  Home  with 
the  following  history:  Since  the  operation  has  never  been 
quite  well,  and  has  had  discomfort  in  the  upper  abdomen, 
coming  on  at  varying  times  after  meals,  but  no  vomiting. 
On  one  or  two  occasions  has  had  attacks  of  severe  pain  in 
the  gall-bladder  region.  There  has  been  no  jaundice.  On 
examination  a  large,  hard  tumour  can  be  felt  beneath  the 
scar  of  the  previous  operation,  and  evidently  connected  with 
the  right  lobe  of  the  liver.  It  reaches  nearly  to  the  umbilicus 
and  passes  just  beyond  the  middle  line.  A  diagnosis  of 
carcinoma  beginning  in  the  gall-bladder  was  made. 

Operation,  June  19,  1909:  Incision  through  old  scar. 
The  peritoneum  was  opened  and  a  finger  passed  in.  A  large 
malignant  mass  was  felt  in  the  region  of  the  gall-bladder,  and 
on  the  upper  surface  of  the  liver  were  numerous  secondary 
nodules.    Abdomen  closed.     Patient  died  several  weeks  later. 

Case  84. — D.  October  26,  1906.  E.  W.,  female,  aged 
nineteen.  For  four  years  had  indigestion  at  intervals.  Worse 
during  the  last  five  months.  Pain  comes  on  about  one  hour 
after  food,  making  her  "sweat."  Is  sharp  and  stabbing  in 
character,  situated  in  epigastrium,  and  radiating  towards 
the  left  side.  Vomits  two  or  three  times  a  week.  Recently 
was  eight  weeks  in  bed  with  rectal  feeding!  but  relapsed 
immediately  on  getting  up. 

Operation:  The  duodenum  for  1)  ■_>  inches  was  covered  with 
scars  and  its  serous  surface  was  shaggy  and  reddened.  There 
were  -omc  enlarged  glands  along  the  loser  curvature,  but  no 
ulcer  was  apparent.  Posterior  gastroenterostomy  by  Mayo's 
method.  Infolding  of  ulcers.  Recovery.  Sent  by  Dr.  Alder- 
ton,  Barnoldswick. 

Report  November  10.  [908:  "Quite  well,  bul  tires  rather 
easily.  Has  gained  considerably  in  weight,  lias  had  one  or 
two  slighl  bilious  attacks,  Inn  otherwise  no  recurrence  of  pain 
nor  vomiting." 

Case  85.  G.  &  D.  November  1.  [906.  Mrs.  M.,  aged 
forty-nine.     For  three  years  has  been  liable  i<>  bouts  of  illness 


380  Duodenal  Ulcer 

in  which  she  suffers  from  loss  of  appetite,  vomiting,  and  a 
feeling  of  discomfort  after  food.  During  the  last  four  months 
she  has  been  worse,  and  although  the  vomiting  has  been  less, 
owing  to  rigid  dieting,  her  appetite  has  almost  completely 
tailed  and  she  has  lost  weight  rapidly.  Two  days  ago  she 
had  a  severe  attack  of  vomiting.  Probably  an  attack  of 
ha?matemesis  at  the  commencement  of  her  illness.  The 
stomach  is  dilated,  with  active  peristalsis;  a  firm  movable 
tumour  palpable  beneath   umbilicus. 

Operation:  Stomach  much  dilated;  a  large  inflammatory 
mass  the  size  of  a  golf  ball  extending  from  pylorus  into  duo- 
denum. Posterior  gastroenterostomy.  Infolding.  Recovery. 
Sent  by   Dr.   Mackenzie,   Manchester. 

Report  November,  1908:  "Am  quite  and  entirely  well; 
can  eat  anything;  have  no  troubles  of  any  kind.  You  made 
an  entire  cure  of  me." 

Case  86. — G.  &  D.  November  8,  1906.  Mrs.  T.,  aged 
thirty-three.  Five  years  ago  a  sudden  attack  of  hsematemesis. 
Two  years  ago  a  second  attack.  Between  these  two  suffered 
almost  all  the  time  from  dyspepsia.  Two  years  ago  in  Nursing 
Home  in  Dublin  under  medical  treatment  for  two  months, 
and  was  better  for  several  months  after.  Recently  a  renewal 
of  pain,  distress,  vomiting.  A  week  ago  a  severe  haemorrhage. 
Haematemesis,  about  10  ounces,  and  melsena.  Several  repe- 
titions of  this.  Now  marked  anaemia,  weakness,  feeble  pulse. 
All  signs  of  continued  bleeding. 

Operation:  An  ulcer  on  the  lesser  curvature  near  the  cardia, 
large  and  hard;  peritoneum  over  it  red  and  shaggy.  A  second 
ulcer  on  the  lower  border  of  the  duodenum  just  beyond 
the  pylorus.  Posterior  gastroenterostomy.  Infolding  of 
duodenal  ulcer.  Recovery.  Sent  by  Drs.  Ryan,  Parsons, 
and  Townsend. 

Report  from  Dr.  Ryan  November,  ,  1908:  "In  better 
health  than  she  has  been  for  years.  Has  gained  considerably 
in  weight.  No  symptoms  of  any  kind.  After  the  operation 
became  quite  healthy  and  strong  and  could  eat  any  kind  of 
food  without  the  least  inconvenience,  despite  the  fact  that 
she  had  been  a  chronic  dyspeptic  for  years.  Before  the  opera- 
tion  she   had    been    fifteen    years   married   and   was  childless. 


Detailed  Statement  of  Cases  Operated  Upon  381 

In  September  last  was  confined  of  a  healthy  child,  and  both 
are  at  present  in  the  best  of  health." 

Case  87. — D.  November  9,  1906.  G.  \V..  male,  aged 
forty.  Ten  years  ago  an  attack  of  pain  in  the  stomach, 
followed  by  vomiting.  Since  then  repeated  attacks.  Now 
has  pain  one  and  one-half  hours  after  food,  never  earlier, 
often  later.  Belching,  flatulence,  acid  eructations.  Appetite 
sometimes  very  keen.  Vomiting  recently;  on  some  occasions 
more  than  a  quart.  Never  hsematemesis  nor  melaena.  Has 
lost  1  stone  4  lbs.  in  three  months.  Stomach  is  very  much 
dilated,  with  obvious  waves. 

Operation:  A  large  chronic  ulcer  on  the  anterior  surface 
of  duodenum.  Posterior  gastro-enterostomy.  Infolding  of 
ulcer.     Recovery.     Sent  by  Dr.  Hebblethwaite,   Keighley. 

Report  November,  1908:  "In  excellent  health;  has  gained 
2  stone  6  lbs.;  no  pain  nor  vomiting  since  operation;  can 
eat  anything;  never  any  discomfort  after  food,  and  bowels 
have  been  quite  regular." 

Case  88. — D.  November  23,  1906.  E.  B.,  female,  aged 
forty-eight.  Quite  well  until  twelve  months  ago,  when  she 
began  to  suffer  from  pain  about  two  hours  after  food,  chiefly 
after  the  mid-day  meal.  The  pain  came  on  in  attacks  lasting 
about  a  week;  after  each  one  she  was  easier  for  a  week  or 
longer.  The  pain  has  become  much  more  severe  recently.  It 
is  always  easier  after  a  little  food.  During  the  last  six  month> 
she  has  vomited  occasionally  a  "sour,  bitter  stuff."  Lost 
2  stone  in  weight  this  year.  A  dilated  waving  stomach. 
Tumour  palpable  in  pyloric  region.     Free  HO  present. 

Operation:  Stomach  dilated  and  thickened;  a  hard  cica- 
tricial ulcer  just  beyond  the  pylorus.  Posterior  gastro-enter- 
ostomy. Ulcer  infolded.  Recovery.  Senl  by  Dr.  Goode, 
I  loncaster. 

Report  November,  1908:  "Patienl  is  much  improved; 
has  gained  7  lbs.;  complains  of  a  little  pain  after  food  at 
times  and  occasional  'water-brash.'  No  vomiting.  Has  been 
much  benefited  by  operation." 

Case  89. — D.  November  24,  [906.  Mr.  Y..  aged  thirty- 
six.  Digestive  troubles  for  six  years.  Pain  three  hours  after 
food,  "hunger  pain."  Appetite  good;  no  vomiting.  Has 
employed  lavage  for  five  years.    Stomach  dilated. 


382  Duodenal  Ulcer 

Operation:  Stomach  dilated.  Scar  of  ulcer  on  anterior 
surface  of  duodenum  1 %  inches  beyond  the  pylorus.  Posterior 
gastroenterostomy.  Ulcer  infolded.  Recover}-.  Sent  by 
Dr.  Briggs,  Blackburn. 

Report  November,  1908:  "Patient  in  better  general 
health  than  he  ever  remembers  to  have  experienced.  Has 
gained  a  few  pounds  in  weight.  No  pain,  no  vomiting.  The 
change  in  the  man's  condition  is  really  wonderful,  and  his 
absolute  freedom  from  every  complaint  quite  different  from 
his  experience  before  operation." 

Case  90. — D.  November  25,  1906.  T.,  male,  aged  fifty. 
Indigestion  for  twenty  years.  Pain  occurs  directly  after  food, 
and  comes  on  in  attacks.  Haematemesis  and  melaena  three 
weeks  ago.     Is  anaemic.     Stomach  not  dilated. 

Operation:  Scars  of  ulcers  in  first  part  of  duodenum. 
Posterior  gastroenterostomy.  Ulcer-bearing  area  infolded. 
Recovery.    Sent  by  Dr.  McLeod. 

Report  November,  1908:  "Patient  is  in  very  good  health — 
better  than  he  has  been  for  the  last  twenty  years.  Has 
gained  considerably  in  weight.  No  recurrence  of  pain  nor 
vomiting." 

Case  91. — D.  December  8,  1906.  Miss  L.,  aged  forty-six. 
Ten  years  ago  had  an  illness  attended  by  enlargement  of  the 
spleen  and  jaundice.  Ever  since  then  has  had  a  large  lump 
on  left  side  of  abdomen,  with  slight  jaundice.  During  all 
this  time  she  has  suffered  from  indigestion.  On  examination 
the  spleen  is  found  to  descend  well  below  the  umbilicus; 
the  stomach  is  very  much  enlarged,  and  frequent  peristaltic 
waves  are  seen. 

Operation:  A  large  ulcer  was  found  in  the  first  part  of  the 
duodenum  adherent  in  the  neighbourhood  of  the  gall-bladder. 
Stomach  much  hypertrophied.  Posterior  gastro-entcrostomy. 
Recovery.    Sent  by  Dr.  Denning,  Elland. 

Report  December,  1908:  "Present  condition  good;  has 
gained  1  stone  in  weight.  Vomits  bile  about  once  a  week. 
It  comes  up  without  effort  and  does  not  make  her  feel  ill. 
Has  no  other  trouble.  Is  working  regularly  in  a  factory  and 
takes  her  food  well." 

Case  92. — D.    December  13,  1906.    Miss  L.,  aged  twenty- 


Detailed  Statement  of  Cases  Operated  Upon  383 

two.  Indigestion  for  six  years.  Pain  half  an  hour  after  food, 
marked  anorexia,  weakness,  no  vomiting.  Tenderness  and 
hyperesthesia  in  centre  of  epigastrium. 

Operation:  Duodenal  ulcer.  Posterior  gastroenterostomy. 
Recovery.     Sent  by  Dr.  Kennedy,  Shepley. 

Report  from  Dr.  Kennedy  December,  1908:  "Has  made 
an  excellent  recovery;  her  general  tone  is  excellent  and  she 
now  enjoys  life.  She  eats  ordinary  food  and  is  really  cured. 
Great  gain  in  weight — should  say  2  stone." 

Case  93. — D.  December  17,  1906.  Mr.  S.,  aged  thirty- 
one.  Indigestipn  for  three  years.  Severe  epigastric  pain  at 
5  P.  M.  and  at  midnight.  Last  meal  in  the  day  is  at  6  P.  M. 
Midnight  pain  often  eased  by  glass  of  soda  and  water.  Occa- 
sional vomiting.  Melaena  but  no  haematemesis.  Stomach  not 
dilated. 

Operation:  A  scar  of  ulcer  just  beyond  the  pylorus.  Pos- 
terior gastroenterostomy.  Infolding  of  ulcer.  Recovery. 
Sent  by  Dr.  Haigh,  Milnsbridge. 

Report  March  6,  1907:  "Has  gained  17  lbs.  and  is  eat- 
ign  anything."  May  27th:  Had  gained  3  stone.  Report 
December,  1908:  "Is  perfectly  well.  Has  gained  42  11  )>. 
He  has  required  no  medical  attendance  since  the  operation, 
and  he  states  that  he  never  felt  so  well.  He  can  take  his  food 
well,  and  never  feels  the  least  discomfort  or  pain  of  any  kind." 

Case  94. — G.  &  D.  December  19,  1906.  Mr.  H.  I).,  male, 
aged  fifty-one.  Indigestion  for  many  years.  For  the  last 
six  months  pain  fairly  regularly  three  hours  after  a  meal. 
No  vomiting  nor  melaena.  Stomach  dilated.  No  visible 
peristalsis. 

Operation:  Scar  of  ulcer  jusl  beyond  pylorus.  One  or 
two  white  scars  on  po-terior  surface  of  stomach.  Posterior 
gastroenterostomy.  Infolding  of  nicer.  Recovery.  Sent 
by  Dr.  Johnstone. 

This  patient  has  been  -ecu  frequently  since  the  operation 
and  is  extremely  well. 

Case  95. — D.     January    10,    1907.     J.    R..    male, 
twenty-nine.    Has  had  pain  in  the  epigastrium  tor  tour  years. 
This  usually  comes  on  about  tour  hours  alter  food.    This  has 
been  much  worse  during  lasl   twelve  months,  and  has  been 


384  Duodenal  Ulcer 

accompanied  by  much  distension  and  flatulence.  Has  lost 
16  lbs.  in  weight.  A  month  ago,  whilst  sitting  in  a  chair, 
suddenly  felt  faint,  sick,  and  vomited  a  large  quantity  of 
blood.  Had  melsena  afterwards  for  ten  days.  On  admission 
to  the  Infirmary  was  pale  and  ill. 

Operation:  Duodenal  ulcer  the  size  of  a  halfpenny  about 
}/2  inch  beyond  the  pylorus.  Posterior  gastroenterostomy. 
Ulcer  infolded.  Recovery.  Sent  by  Drs.  Hawkyard  and 
Mathieson,  Leeds. 

Report  November,  1908:  "Is  well  nourished  and  feels 
well.  Has  gained  3  stone  in  weight.  No  recurrence  of  pain 
nor  vomiting.     Is  following  his  work  as  a  labourer." 

Case  96. — D.  January  11,  1907.  Mrs.  H.,  aged  thirty- 
seven.  Had  symptoms  for  five  years.  Pain  one  and  One- 
half  to  two  hours  after  food.  Vomiting.  Tenderness  along 
right  costal  margin. 

Operation:  Stomach  much  dilated.  Scar  of  ulcer  in  first 
part  of  duodenum.  Posterior  gastro-enterostomy  and  infold- 
ing of  ulcer.     Recovery.     Sent  by  Dr.  Falkner,  Hull. 

Report  November,  1908:  "Feels  better  than  she  has  done 
for  years.  She  seems  to  be  perfectly  well,  and  eats  and  drinks 
anything." 

Case  97. — G.  &  D.  February  1,  1907.  Mrs.  G.,  aged 
forty-six.  Indigestion  for  six  years.  Pain  about  two  hours 
after  food.  Occasional  melsena.  Six  weeks  ago  she  had 
several  attacks  of  faintness  and  vomited  blood  twice.  This 
was  followed  by  melsena. 

Operation:  Indurated  ulcer  felt  in  posterior  wall  of  first 
part  of  duodenum.  A  slight  scarring  on  posterior  wall  of 
stomach.  Posterior  gastro-enterostomy.  Duodenum  in- 
folded.    Recovery.     Sent  by  Dr.  Knowles,  Barnsley. 

Report  November,  1908:  "Is  very  well.  Has  gained 
nearly  2  stone.     No  trouble  at  all." 

Case  98. — G.  &  D.  February  1,  1907.  J.  W.  H.,  male, 
aged  sixty-five.  Has  had  serious  stomach  trouble  on  and  off 
for  more  than  twenty  years,  and  has  been  in  the  Infirmary 
on  the  medical  side  several  times.  On  examination  a  much 
emaciated,  haggard  man;  weighs  6  stone.  Has  lost  I  stone 
in  the  last  fortnight.     Stomach  dilated;   visible  peristalsis. 


Detailed  Statement  of  Cases  Operated  Upon  385 

Operation:  Innumerable  adhesions,  making  exploration  of 
stomach  very  difficult.  (Old  perforation?)  Pylorus  and 
duodenum  thick  and  cicatricial.  First  part  of  jejunum  very 
adherent  to  under  surface  of  transverse  mesocolon.  Posterior 
gastroenterostomy.  Recovery.  Transferred  from  Dr.  Chur- 
ton's  care. 

This  patient  cannot  be  traced. 

Case  99. — D.  February  8,  1907.  W.  H.  H.,  male,  aged 
thirty-eight.  Attacks  of  indigestion  for  several  years.  The 
present  attack,  which  is  just  subsiding,  began  in  November 
last.  He  has  pain  at  varying  intervals  after  meals.  This 
is  worse  between  3.30  and  4  p.  M.  and  lasts  until  the  next 
meal,  which  relieves  it.  As  a  rule,  the  pain  comes  two  and 
one-half  hours  after  meals,  and  is  almost  always  relieved  by 
King  down.  Appetite  good.  Has  lost  7  lbs.  in  the  last  five 
weeks,  but  is  well  nourished  and  plump. 

Operation:  A  duodenal  ulcer  about  the  size  of  a  sixpence 
on  the  anterior  surface  of  the  duodenum  just  beyond  pylorus. 
Posterior  gastroenterostomy.  Infolding  of  ulcer.  The 
patient  did  well  until  the  21st;  was  eating  well  and  said  he 
was  very  hungry.  On  the  21st  he  was  allowed  to  get  up.  He 
had  not  been  up  more  than  two  minutes  before  he  complained 
of  acute  abdominal  pain,  vomited,  and  went  back  to  bed. 
That  night  he  vomited  twice,  but  on  the  morning  of  the  22d 
seemed  better.  In  the  evening  he  vomited  three  times  and 
had  a  temperature  of  1030.  Next  morning  he  was  very  ill, 
and  the  abdomen  was  reopened.  No  free  fluid  was  found  in 
the  peritoneal  cavity;  the  coils  of  small  intestine  were  slightly 
injected.  The  anastomosis  was  inspected,  and  in  order  to 
expose  il  some  adhesions  between  the  distal  loop  of  the 
jejunum  and  under  surface  of  tin-  mesocolon  had  to  be  sepa- 
rated. Jusl  distal  to  the  anastomosis  .1  perforation  in  the 
jejunum  was  exposed,  evidently  a  jejunal  ulcer  which  had 
perforated  subacutely.  It  was  impossible  to  close  this  per- 
foration without  disconnecting  the  anastomosis.  This  was 
done,  the  ulcer  excised,  the  opening  in  the  stomach  closed, 
and  a  second  anastomosis  performed  away  from  the  first 
position.  The  patient  died.  Senl  by  Mr.  J.  I'.  Rough  ton, 
Kit  tering. 
2; 


386  Duodenal  Ulcer 

Case  100. — G.  &  D.  March  1,  1907.  Mr.  C,  aged  fifty. 
Digestive  troubles  for  a  very  long  time.  Milk  diet  for  some 
months.  Pain  and  flatulence  after  meals.  Now  the  pain  is 
more  or  less  continuous,  being  relieved  by  a  drink  of  milk, 
only  to  recur  in  half  an  hour's  time.  Occasional  vomiting; 
loss  of  weight.  Tenderness  in  centre  of  epigastrium,  spreading 
downwards  to  right.     Stomach  slightly  dilated. 

Operation:  An  ulcer  on  the  anterior  wall  of  the  duodenum 
just  beyond  pylorus.  Thickening  of  ulcer  also  felt  on  great er 
curvature  near  pylorus.  Adhesions  in  lesser  sac  and  an  ulcer 
felt  on  posterior  wall  close  to  lesser  curvature.  Posterior 
gastroenterostomy.     Recovery. 

This  patient  was  much  relieved  for  one  year,  but  then 
began  to  suffer  from  pain  and  distension  two  hours  after  food, 
with  occasional  vomiting  of  yellow,  bilious  material.  By 
August,  1908,  his  pain  was  rather  worse;  had  no  appetite 
and  was  losing  weight.  A  malignant  change  in  the  ulcerated 
area  was  suspected. 

Operation  August  21,  1908:  The  scars  of  previously 
existing  ulcers  were  apparent,  but  there  was  no  induration 
and  no  evidence  of  malignancy;  pylorus  freely  patent.  Some 
adhesions  about  the  anastomosis,  but  apparently  of  no  impor- 
tance. The  afferent  limb  of  the  jejunum  shewed  a  slight 
"loop."  Division  of  afferent  limb  close  to  anastomosis  and 
end-to-side  implantation  into  efferent;  pylorus  narrowed  by 
suture.     Recovery.     Sent  by  Dr.  Marsden,  Lightcliffe. 

Report  September,  1909:  Patient  states  that  he  has 
suffered  from  frequent  attacks  of  flatulence  since  his  last 
operation,  but:  no  vomiting.  A  ventral  hernia  has  developed 
at  the  site  of  the  second  operation,  but  a  belt  has  been  ordered 
and  is  being  worn.  On  the  whole,  he  is  better,  but  considers 
himself  far  from  well. 

Case  101. — D.  March  13,  1907.  Mrs.  T.,  aged  thirty- 
nine.  Stomach  trouble  for  ten  years.  Epigastric  pain  two 
hours  after  food,  with  occasional  vomiting.  No  haematemesis; 
loss  of  weight.  Tenderness  in  middle  of  epigastrium;  stomach 
dilated,  with  visible  peristalsis. 

Operation:  Stomach  dilated  and  much  proptosed,  the 
lowest  point  of  the  lesser  curvature  being  at  the  level  of  the 


Detailed  Statement  of  Cases  Operated  Upon   387 

umbilicus.  Above  this  the  pancreas  was  clearly  visible.  A 
well-marked  ulcer  on  the  upper  border  of  the  duodenum,  jusl 
beyond  pylorus.  Posterior  gastroenterostomy.  Infolding 
of  ulcer.  Recovery.  Sharp  attack  of  bronchitis  after  opera- 
tion.    Sent  by  Dr.  A.  Court. 

Report  November,  1908:  "Has  gained  about  2  stone 
There  has  been  no  recurrence  of  pain.  Appetite  is  excellent 
and  she  eats  practically  anything." 

Case  102. — D.  March  28,  1908.  H.  C,  male  aged  thirty- 
seven.  In  November  last  began  to  suffer  from  sharp,  colicky 
pain  in  the  abdomen  in  attacks  lasting  five  or  six  days.  Before 
and  after  the  attacks  suffers  from  great  flatulence  and  belching. 
No  vomiting.     Stomach  large. 

Operation:  A  duodenal  ulcer  just  beyond  pylorus.  Pos- 
terior gastroenterostomy.  Recovery.  Sent  'by  Dr.  La 
Touche,  Ossett. 

Report  November,  1908:  "Is  in  good  health.  Has  gained 
2  stone  since  the  operation.  No  return  of  pain  nor  vomiting. 
Has  not  been  off  work  since  he  resumed  six  months  alter  the 
operation." 

Case  103. — D.  April  12,  1907.  T.  C,  male,  aged  thirty- 
nine.  Has  suffered  from  indigestion  for  the  last  five  years. 
Pain  in  epigastrium  about  one  hour  after  food,  with  a  feeling 
of  fullness  and  depression.  Last  October  vomiting  began  and 
pain  after  food  was  later  in  onset.  Now  lias  a  greal  distaste 
for  food.     The  stomach  is  dilated. 

Operation:  A  duodenal  ulcer  making  a  mass  the  size  of  a 
walnut  just  beyond  the  pylorus.  The  omentum  was  very 
adherent  over  it.  (Subacute  perforation?)  Posterior  gastro- 
enterostomy.    Recovery.     Sent  by  Dr.  McGibbon,  Bramley. 

Report  November,  [908:  "Is  robust  and  perfectly  healthy. 
Has  gained  3^2  stone.  Has  had  no  recurrence  of  symptoms 
al   all.     Appetite  is  extremely  good  and  can  eat  anything." 

Case  104. — D.  May  24,  1007.  A.  ()..  female,  aged 
titty-tour.  Was  quite  well  until  six  months  ago,  when  she 
in  to  suffer  from  pain  after  food  and  vomiting.  Pain 
usually  came  two  hours  after  food  and  was  relieved  l>\  vomil 
ing  or  by  taking  more  food.  Has  losl  3  stone  in  weight. 
Visible  peristalsis. 


388  Duodenal  Ulcer 

Operation:  A  duodenal  ulcer  about  as  large  as  a  sixpence 
about  34  inch  beyond  pylorus.  Posterior  gastroenterostomy. 
Infolding  of  ulcer.  Recovery.  Sent  by  Dr.  Carter  Mitchell, 
Topclifife. 

Report  November,  1908:  "Is  much  improved;  has  gained 
18  lbs.  in  weight.  Has  occasional  attacks  of  pain  in  left 
hypochondrium,  striking  through  to  the  back,  accompanied 
by  bilious  vomiting.  Has  also  some  heartburn.  However, 
says  she  is  quite  a  different  person  since  operation.  Before 
that  she  never  had  an  hour  free  from  pain  or  vomiting,  but 
is  now  able  to  work,  although  she  has  occasional  pain." 

Case  105. — D.  May  26,  1907.  L.  W.,  female,  aged 
twenty-six.  Indigestion  for  eight  or  nine  years.  Pain  occur- 
ring one  and  one-half  to  three  hours  after  food,  with  much 
flatulence.  -Food  always  relieves  pain.  Three  attacks  of 
haematemesis  during  the  last  six  years. 

Operation:  Small  duodenal  ulcer.  Posterior  gastroenter- 
ostomy.    Sent  by  Dr.   Foley,  Scarborough. 

Report  November,  1908:  "Has  gained  nearly  a  stone  in 
weight.  Still  has  to  be  careful  of  her  diet,  and  has  occasional 
neuralgic  abdominal  pains,  but  no  pain  similar  to  before 
operation.  No  vomiting.  Is  decidedly  better,  but  cannot 
do  much  hard  work." 

Case  106. — D.  May  27,  1907.  Mr.  T.,  aged  forty-six. 
Has  suffered  from  gastric  symptoms  for  twenty  years.  Pain 
two  or  three  hours  after  food,  which  was  relieved  by  a  meal. 
Intervals  of  complete  freedom  between  the  attacks.  No 
history  of  haematemesis  nor  mekena.  Recently  there  has  been 
no  severe  pain,  but  much  flatulence,  relieved  by  vomiting. 
Has  lost  20  lbs.  in  the  last  three  months.  Stomach  is  dilated; 
visible  peristalsis. 

Operation:  Stomach  much  dilated;  ulcer  in  the  first  part 
of  the  duodenum,  producing  stenosis.  Posterior  gastroenter- 
ostomy by  Mayo's  method.  Recovery.  Sent  by  Dr.  David- 
son, Hipperholme. 

Report  October,  1908:  "In  splendid  health;  gained  two 
stone;  has  been  very  well  ever  since  operation,  and  can  now 
eat  and  drink  anything." 

Case    107. — D.     May  29,  1907.     Mrs.  D.,  aged  forty-two. 


Detailed  Statement  of  Cases  Operated  Upon  389 

For  fifteen  years  has  suffered  from  attacks  of  indigestion 
and  flatulence.  Five  years  ago  severe  attack  with  vomiting 
of  coffee-ground  material.  Recently  has  suffered  from  attacks 
of  pain  immediately  after  food,  often  lasting  all  day.  During 
these  attacks  vomiting  is  frequent.  Has  lost  12  lbs.  in  weight. 
The  greater  curvature  of  the  stomach  reaches  below  the 
umbilicus;  feeble  peristalsis. 

Operation:  Stomach  dilated.  Scar  of  an  ulcer  about  the 
size  of  a  florin  in  first  part  of  duodenum.  Posterior  gastro- 
enterostomy. Infolding  of  ulcer.  Recovery.  Sent  by  Dr. 
Bruce  Low,  Sunderland. 

Report  November,  1908:  "Fairly  healthy,  but  there  is  no 
substantial  increase  in  weight.  No  recurrence  of  pain  nor 
vomiting  and  can  take  ordinary  diet." 

Case  108. — G.  &  D.  June  7,  1907.  E.  H.,  female,  aged 
forty-one.  An  attack  of  pain  and  vomiting  after  food  when 
sixteen  years  old.  Similar  illness  when  she  was  twenty-one, 
and  another  when  she  was  thirty-three.  In  the  last  she  was 
very  seriously  ill;  great  pain  soon  after  food,  vomiting,  and 
haematemesis.  Four  years  ago  she  again  began  to  have  pain 
after  food,  having  been  quite  well  since  the  former  attack. 
The  pain  then  came  two  hours  after  food,  was  always  relieved 
by  vomiting,  and  sometimes  by  food.  A  similar  attack  two 
years  ago,  and  a  third  in  February  of  this  year. 

Operation:  A  large  indurated  ulcer  on  lesser  curvature 
near  the  cardia  had  narrowed  the  stomach  and  produced  an 
hour-glass  contraction.  A  large,  indurated,  duodenal  ulcer. 
I  Gastroplasty.  Gastroenterostomy.  Recovery.  Sent  by  Dr. 
I  >owsing,  Hull. 

Report  November,  [908:  "Has  gained  14  lbs.  Has  had 
no  pain  and  no  vomiting  since  operation,  and  is  in  better 
health  than  she  has  been  for  twenty  years." 

Case  [09.  I).  June  7.  1007.  \Y.  H.  I).,  male,  aged 
forty-nine.  Two  years  ago  began  to  have  pain  a  long  time 
after  food,  "consisting  chiefly  of  wind  and  sour  eructations." 
The  pain,  he  says,  "was  not  due  to  food,  because  it  was  much 
better  for  an  hour  or  two,  and  then  ii  began  to  come  on  ^v.\t\- 
ually  and  gol  severe."  It  was  always  quickly  relieved  l>\ 
tood.     Food  used  to  repeat   "very  hot"  aboul  an  hour  after 


390  Duodenal  Ulcer 

meals.  Has  lost  I  stone  in  weight.  Never  any  haemorrhage. 
A  dilated  waving  stomach. 

Operation:  A  large  ulcer  or  ulcers  extending  over  i}4  inches 
of  the  duodenum,  with  warping  and  puckering  of  the  surface. 
Man)  recent  adhesions.  Posterior  gastroenterostomy.  Re- 
covery.   Sent  by  Dr.  Haigh,  Milnsbridge. 

Report  November,  1908:  "Is  perfectly  well;  has  gained 
20  lbs.  Has  not  required  any  medical  attendance  since  the 
operation;  states  that  he  has  not  felt  so  well  for  five  or  six 
years,  and  he  can  take  any  kind  of  food  without  the  least 
discomfort. 

Case  iio. — D.  June  8,  1907.  R.  T.,  male,  aged  fifty- 
rive.  For  twenty  years  has  had  attacks  of  indigestion,  all 
moderately  severe  during  the  few  weeks  they  lasted,  but  he 
has  been  well  in  the  intervals.  Three  months  ago  began  to 
suffer  similarly,  but  this  attack  has  been  much  more  severe 
and  he  has  lost  weight  rapidly.  Pain  comes  one  or  two  hours 
after  food,  and  he  has  severe  flatulence  and  sour  eructations. 

Operation:  An  ulcer  in  the  anterior  wall  of  the  duodenum, 
immediately  beyond  pylorus.  There  were  evidences  of  old 
tubercular  disease,  adhesions  of  intestines,  and  old  calcareous 
glands  in  the  mesentery.  Posterior  gastroenterostomy. 
Recovery.     Sent  by  Dr.   Lambert,   Farsley. 

Report  November,  1908:  Now  in  fairly  good  health;  one 
attack  of  pain  in  April,  lasting  about  three  weeks.  Has 
worked  every  day  except  during  attack  mentioned. 

Case  hi. — D.  June  12,  1907.  Mr.  M.,  aged  sixty-seven. 
Has  suffered  as  long  as  he  can  remember  from  "delicate 
stomach."  Great  flatulence  after  eating,  especially  vege- 
tables. For  the  last  thirty-one  and  one-half  years  has  held 
the  same  living,  and  all  through  this  period  has  had  occasional 
attacks  of  indigestion,  acidity,  flatulence,  and  disinclination 
for  food.  Three  and  one-half  years  ago  severe  haematemesis 
and  melaena.  The  vomit  was  then  so  acid  that  it  burnt  the 
throat  and  lips  on  ejection.  Since  then  several  attacks  of 
acid  vomiting.  The  stomach  was  not  dilated.  It  was  thought 
that  peristalsis  was  visible. 

Operation:  An  old  and  very  hard  duodenal  ulcer,  causing 
a  faint  amount  of  stenosis.     Many  adhesions  of  duodenum  to 


Detailed  Statement  of  Cases  Operated  Upon  391 

gall-bladder.  The  upper  part  of  the  jejunum  was  buried  in 
adhesions,  which  had  to  be  divided  before  gastroenterostomy 
could  be  performed.    Posterior  gastroenterostomy..    Recovery. 

Report,  letter,  February,  1909:  "The  operation  has  proved 
a  complete  success.  I  have  had  no  pain  whatever,  no  flatu- 
lence such  as  I  suffered  from  for  years  before,  and  my  digestion 
is  quite  regular." 

Case  112. — D.  June  13,  1907.  Mr.  S.,  aged  forty-five. 
Up  to  November,  1906,  suffered  from  attacks  of  acute  epi- 
gastric pain,  coming  on  some  hours  after  food,  and  usually 
followed  and  relieved  by  vomiting.  Occasionally  food  seemed 
to  relieve  the  pain.  Xo  hrematemesis  nor  melsena.  Since 
November  last  pain  almost  continuous  during  the  day,  but 
not  present  at  night.  He  describes  it  as  a  dull  aching  pain 
near  the  umbilicus  and  down  to  lower  part  of  abdomen. 
No  vomiting  since  November.  Bowels  constipated.  Has 
lost  weight  rapidly  lately  (60  lbs.).  A  large,  gaunt  man. 
Stomach  reaches  to  umbilicus. 

Operation:  The  stomach  is  dilated  and  coats  thickened. 
On  the  anterior  surface  of  the  first  part  of  the  duodenum  an 
indurated  ulcer.  A  circular  deposit  of  tuberculous  disease 
about  the  centre  of  the  transverse  colon.  The  ileo-csecal 
junction,  ca?cum,  and  appendix  were  more  extensively  in- 
volved. The  deposits  were  not  of  the  hyperplastic  form,  but 
the  peritoneum  was  red,  granular,  and  covered  1>\  small 
tubercles;  no  stenosis.  One  or  two  large  glands  in  the  mes- 
entery. Posterior  gastroenterostomy.  Infolding  of  ulcer, 
which  was  probably  tuberculous.  The  patient  died  four- 
teen da>s  after  the  operation  with  signs  of  acute  phthisis 
(generalising  tuberculosis).     No  post-mortem  examination. 

Case  113. — D.  June  23,  1907.  Mr.  S.  R..,  aged  sixty- 
five.  Periodic  attacks  of  severe  pain  one  and  one-half  hours 
after  food  for  fourteen  years.  The  pain  is  heavy  and  aching, 
accompanied  by  much  flatulence,  and  is  relieved  by  food. 
There  has  been  no  vomiting.  The  present  attack  has  lasted 
eight  or  nine  months.  Hehaslosl  4  stone  4  lbs.  The  stomach 
reaches  to  the  level  of  the  umbilicus.  A  tender  spol  above 
and  to  the  righl  of  the  umbilicus. 

Operation:     Ulcer  in    firsl    pari    of  duodenum.      Posterior 


392  Duodenal  Ulcer 

gastro-enterostomy.  Infolding  of  ulcer.  Recovery.  Sent  l>y 
Dr.  Watterson,  Morecambe. 

Report  from  Dr.  Watterson  September,  1909:  "I  am 
sorry,  but  I  really  cannot  obtain  any  satisfactory  information 
from  him  as  to  result  of  operation.  He  persists  in  saying  that 
he  is  no  better  than  when  under  my  care  before  the  operation. 
He  goes  about  regularly,  and  I  believe,  as  I  have  stated  to 
him,  that  he  is  better  for  the  operation.  I  will  tell  you  more 
when  next  I  see  you.     He  is  'perverse'  in  nature." 

Case  114. — D.  July  7,  1907.  H.  S.,  male,  aged  twenty- 
seven.  Twelve  months  ago  for  four  or  five  days  an  attack 
of  "indigestion,"  with  great  flatulent  distension,  eructations, 
and  a  feeling  of  nausea.  He  attributed  all  this  to  smoking 
a  new  pipe.  On  March  21st,  after  feeling  run  down  and  low 
for  a  few  days,  he  suddenly  fainted,  and  had  to  be  taken 
home.  For  several  days  there  was  profuse  melaena,  and  this 
has  been  almost  constant  since  then.  Has  been  rigidly  re- 
stricted to  fluids,  and  during  this  time  has  had  no  indigestion. 

Operation:  A  small  round  ulcer  on  the  anterior  wall  of  the 
duodenum.  This  was  excised.  On  the  posterior  wall  exactly 
opposite  was  a  precisely  similar  ulcer,  which  was  sutured. 
Duodenum  closed.  Posterior  gastro-enterostomy.  Recovery. 
Sent  by  Dr.  Malim,  Rochdale. 

Report  December,  1908:  "Patient  is  in  good  health. 
There  has  been  no  recurrence  of  pain  nor  vomiting." 

Case  115. — D.  July  8,  1907.  W.  J.,  male,  aged  forty- 
seven.  Quite  well  up  to  six  months  ago;  then  began  to  suffer 
from  pain  beneath  the  right  costal  margin.  This  was  worse 
two  hours  after  a  meal,  and  continued  until  the  next  meal. 
Recently  pain  has  been  very  acute,  with  much  epigastric 
distension  and  eructation  of  sour  fluids.  Frequently  the  pain 
wakes  him  at  night.  Food  relieves  pain  better  than  anything 
else. 

Operation:  A  fairly  large  ulcer  1  inch  beyond  pylorus. 
Posterior  gastro-enterostomy.     Recovery. 

Report  from  patient  November,  1908:  "I  have  derived 
a  great  deal  of  benefit  from  the  operation,  and  have  not  felt 
as  well  as  I  do  now  for  many  years  past." 

Case  116. — D.     June   11,    1907.     F.,   medical   man,   aged 


Detailed  Statement  of  Cases  Operated  Upon  393 

fifty-eight.  Five  years'  history.  Severe  epigastric  pain, 
occurring  about  two  hours  after  food.  These  attacks  would 
last  two  or  three  months,  and  then  disappear  perhaps  for 
four  or  five  months.  Attacks  coincident  with  winter  and 
overwork.  During  the  last  three  years  attacks  have  increased 
in  number  and  severity  and  he  has  suffered  much  from  pain 
about  2  a.  m.  The  pain  is  always  relieved  by  taking  food; 
has  never  vomited.  Blood  has  been  detected  in  the  stools 
by  microscopic  examination.  A  fairly  well-nourished  man. 
No  gastric  dilatation. 

Operation:  Duodenum  shewed  severe  scarring  by  two,  or 
possibly  three,  ulcers  in  its  first  portion.  The  duodenum 
was  tucked  back  by  adhesions  to  the  under  surface  of  the  liver. 
Posterior  gastroenterostomy.  Infolding  of  ulcer.  Recovery. 
Sent  by  Dr.  Craven  Moore,  Manchester. 

Report:  This  patient  has  been  seen  quite  recently,  and  is 
extremely  well  and  entirely  free  from  his  old  trouble. 

("ask  117. — D.  July  19,  1907.  Miss  St.  G.,  aged  twenty- 
five.  Six  years  ago  an  attack  of  catarrhal  jaundice.  For 
four  years  has  suffered  from  indigestion,  severe  gnawing  pain 
coming  on  two  hours  after  food,  which  was  occasionally 
relieved  by  food.  There  has  been  no  vomiting  and  no  melsena  ; 
there  is  no  gastric  dilatation. 

Operation:  An  ulcer  in  the  first  part  of  the  duodenum. 
Posterior  gastroenterostomy.  Infolding  of  ulcer.  Recovery. 
Sent   by  Major  Porter,  D.S.O.,  R.A.M.C,  Colchester. 

Report:  A  letter  from  patient,  January  25,  1909,  states 
that  she  had  attacks  of  indigestion  and  nausea  for  about 
six  months.  Since  then  these  have  gradually  become  more 
infrequent  and  she  has  gained  weight.  At  the  present  time 
i-  very  well,  and  is  enjoying  winter  sports  in  Switzerland. 

Case  118. — D.     July   22,    i<)07.     \\\,   male,   aged   forty. 

Since  the  age  of  fifteen  attacks  of  pain  occurring  tWO  and  one- 
half    hours    after    food,    with    frequent     vomiting    of    \v\\   acid 

fluid.  Pain  i>  usually  relieved  by  food.  Between  the  attacks 
he  has  had  varying  intervals  <>l  relief.  No  haematemesis,  no 
melsena.  riaslosl  3  stone  in  weight.  Slight  gastric  dilatation. 
Operation:  Several  ulcers  in  firsl  and  second  parts  ol  the 
duodenum,  which  had  produced  much  scarring  and  deformity. 


394  Duodenal  Ulcer 

Posterior  gastro-enterostomy.  Infolding  of  ulcerated  area. 
•Recover)".     Sent  by  Dr.  Dowsing  of  Hull. 

Report  December,  1908:  "Is  in  very  good  health;  has 
gained  4  stone  in  weight  since  the  operation.  Has  not  been 
so  well  as  he  is  now  for  ten  years,  and  his  only  regret  is  that 
he  did  not  have  the  operation  done  sooner." 

Case  119. — D.  July  22,  1907.  B.,  male,  aged  fifty-one. 
Trouble  for  three  years.  Pain  two  or  three  hours  after  food, 
frequently  accompanied  by  vomiting.  Food  relieves.  At 
first  there  were  intervals  of  relief,  but  latterly  pain  has  been 
almost  constant. 

Operation:  Duodenum  tucked  back  beneath  liver;  ulcer 
in  first  portion.  Posterior  gastro-enterostomy.  Infolding  of 
ulcer.     Recovery.     Sent  by  Dr.  Burnett,  Saltburn. 

Report  December,  1908:  "Patient  was  much  improved 
several  months  after  the  operation  and  was  free  from  pain, 
and  at  that  time  returned  to  America.  No  report  received 
since." 

("ask  120. — D.  August  6,  1907.  O.  F.,  male,  aged  thirty- 
two.  The-  last  three  years  has  had  pain  occurring  two  and 
one-half  hours  after  food.  At  the  onset  of  his  illness  an  attack 
of  hecmatemesis,  which  has  not  recurred.  No  mela-na.  Has 
losi   1 Y2  stone  in  the  last  six  months. 

Operation:  A  duodenal  ulcer  just  beyond  pylorus.  Poste- 
rior gastro-enterostomy.  Recovery.  Sent  by  Dr.  Dearden, 
Wyke. 

Report  May,  1909:  "Patient  has  ailed  nothing  since  the 
operation.  Is  now  extremely  well  and  has  no  trouble  of  any 
sort." 

Case  121. — D.  August  9,  1907.  H.  J.  H.,  female,  aged 
forty-six.  For  the  last  nine  years  has  suffered  from  pain, 
fullness,  and  discomfort  at  varying  periods  between  one  and 
three  hours  after  food.  Immediately  after  food  she  is  quite 
comfortable,  and  she  can  manage  to  keep  so  by  "nibbling" 
all  day,  but  at  night  the  pain  nearly  always  wakes  her  up. 
\o  dilatation. 

Operation:  A  large  indurated  ulcer  just  beyond  the  py- 
lorus. Posterior  gastro-enterostomy.  Infolding  of  ulcer. 
Recovery.     Sent  by  Dr.  Oldfield. 


Detailed  Statement  of  Cases  Operated  Upon  395 

Report  December,  1908:  "Very  much  improved.  Her 
general  condition  was  poor  for  six  months  after  the  operation. 
Due  in  part  to  chronic  pleurisy  (probably  tuberculous),  and 
in  part  to  her  not  taking  sufficient  meat  food,  which  she 
thought  was  unsuitable.  She  has  now  gained  considerably 
in  weight,  and  is  better  than  she  has  been  for  twenty  years." 

Case  122. — G.  &  D.  August  14,  1907.  W.  B.,  male,  aged 
twenty-six.  For  five  years  has  suffered  from  pain  two  to 
three  hours  after  food,  which  is  always  relieved  by  the  next 
meal.  A  few  days  before  admission  had  copious  melaena  and 
some  haematemesis,  which  continued  for  fourteen  days  after 
admission. 

Operation:  An  ulcer  on  the  lesser  curvature  of  the  stomach 
near  pylorus;  a  second  large  ulcer  in  the  first  part  of  the 
duodenum.  Posterior  gastroenterostomy.  Infolding  of 
ulcer.    Recovery-    Sent  by  Dr.  Isaac  Taylor,  Leeds. 

Report  July,  1909:  "The  operation  has  been  a  wonderful 
success;  has  gained  11  lbs.  and  has  never  vomited  since  the 
operation." 

Case  123. — D.  August  16,  1907.  R.  T.,  male,  aged 
thirty.  Has  had  "stomach  trouble"  since  he  was  fourteen 
or  fifteen.  Pain  at  first  was  so  bad  as  to  double  him  up. 
Pain  in  the  last  few  years  has  sometimes  come  one  hour 
after  food,  but  more  commonly  two  or  three  hours  after. 
Frequent  vomiting  of  yeasty  material.  A  large  waving 
stomach. 

Operation:  A  well-marked  ulcer  just  beyond  pylorus  with 
a  good  deal  of  induration.  Posterior  gastro-enterostomy. 
Recovery.    Sent  l>y  Dr.  Andrews,  Burmantofts. 

Report  October  4.  1007:  "Gained  in  weighl  and  cm  eat 
anything."  Reporl  November,  [908:  "Is  in  perfeel  health; 
ha--  gained  2  -tone.  Has  had  absolutely  no  recurrence  of 
symptoms,  and  there  are  now  no  signs  of  gastric  dilatation." 

Case  124. — D.  Augusl  20.  1007.  \\ .  A.,  male,  aged 
fifty-eight,  lor  several  years  has  had  discomforl  of  varying 
degrees  "i  severity  after  food.  Twenty  months  ago  a  severe 
blow  in  the  epigastrium,  and  since  then  he  ha-  been  much 
worse.  Eighteen  month-  ago  began  to  lose  weight,  and  in  all 
has  lost   over  3  -tone.     Has  pain  usually  three  to  three  and 


396  Duodenal  Ulcer 

one-half  hours  after  food,  and  latterly  much  flatulence,  eruc- 
tation, and  acidity.  Four  months  ago  a  severe  attack  of 
melsena,  and  two  days  later  haematemesis.  Stomach  dilated; 
no  visible  peristalsis. 

Operation:  A  large  mass,  smooth  and  hard,  involving  the 
duodenum  in  its  first  and  second  parts.  Posterior  gastro- 
enterostomy and  closure  of  pylorus.  Recovery.  Sent  by 
Dr.  Wilkinson,  Starbeck. 

Report  December,  1908:  "  Patient  enjoys  excellent  health; 
has  gained  10  to  12  lbs.  in  weight,  and  is  now  able  to  follow 
his  former  occupation  of  postmaster,  which  he  was  com- 
pelled to  relinquish  some  months  previous  to  his  operation." 

Case  125. — D.  September  2,  1907.  N.,  male,  aged 
thirty-seven.  For  four  or  five  years  has  been  troubled  with 
a  feeling  of  weight  soon  after  food,  followed  in  two  or  three 
hours  by  an  acute  cutting  pain.  Frequent  acid  eructations. 
Food  usually  relieves. 

Operation:  The  duodenum  was  firmly  tucked  back  beneath 
liver;  a  small  ulcer  just  beyond  pylorus.  Posterior  gastro- 
enterostomy. Infolding  of  ulcer.'  Recovery.  Sent  by  Dr. 
J.    Nicholson,    Roundhay. 

Report  January,  1909:  "Patient's  condition  is,  speaking 
generally,  good.  There  has  been  a  gain  of  about  11  lbs.  in 
weight.  He  still  complains  of  pain  coming  on  about  an  hour 
after  food,  and  slight  regurgitation  of  acid  mucus  into  the 
mouth." 

Case  126. — D.  September  3,  1907.  G.,  male.  Indiges- 
tion for  many  years.  Pain  two  or  three  hours  after  food, 
relieved  by  vomiting  of  frothy  mucus.  The  pain  is  frequently 
worse  at  night.  No  haematemesis.  History  of  mela'na. 
Between  the  attacks  there  have  been  intervals  of  complete 
freedom.  Has  lost  3  stone  in  weight,  and  lately  has  become 
markedly  anaemic.  The  stomach  contents  contain  no  free 
HC1  and  lactic  acid  is  present.  There  is  no  obvious  dilata- 
tion of  stomach  and  no  tumour  can  be  palpated. 

Operation:  No  ulcer  or  growth  in  stomach;  a  duodenal 
ulcer  just  beyond  pylorus.  Posterior  gastroenterostomy. 
Infolding  of  ulcer.     Recovery.    Sent  by  Dr.  Sadler,  Barnsley. 

Report  December,   1908:     "I  have   enjoyed  better   health 


Detailed  Statement  of  Cases  Operated  Upon  397 

this  last  year  than  in  any  year  since  1878.  I  can  eat  with 
impunity  things  I  have  not  ventured  to  touch  for  many 
years.  I  have  gained  over  2  stone  in  weight.  The  operation 
has  made  a  new  man  of  me,  and  whereas  life  was  for  many 
years  a  miserable  burden,  it  is  now  a  pleasure." 

Case  127. — D.  September  7,  1907.  McG.,  male,  aged 
twenty -five.  Five  years  ago  received  a  kick  in  the  abdomen 
while  playing  football,  and  has  never  been  quite  fit  since 
then.  For  the  last  two  years  attacks  of  pain  in  lower  part  of 
chest  and  epigastrium,  coming  on  at  first  half  an  hour,  and 
latterly  two  hours,  after  food.  Much  flatulence  and  regur- 
gitation of  sour  fluid  into  mouth.  Food  often  relieves  pain. 
Has  had  intervals  of  complete  freedom  between  the  attacks. 
At  least  one  attack  of  melaena;  has  lost  I  stone  in  weight. 

Operation:  Duodenum  fixed  tightly  back  beneath  liver; 
a  star-shaped  scar  and  ulcer  in  first  portion.  Posterior  gastro- 
enterostomy. Infolding  of  pylorus.  Recovery.  Sent  by 
Dr.   Leatham,   Belfast. 

Report  January,  1909:  For  a  time  improvement  in  this 
case  was  very  slow;  burning  in  the  epigastrium  recurred  on 
any  indiscretion  in  diet,  and  there  was  no  great  gain  of  weight, 
but  during  the  last  two  months  of  1908  the  burning  disap- 
peared, and  improvement  became  so  marked  that  the  patient 
considers  himself  completely  cured.  A  report  received  during 
July,  1909,  stated  that  this  patient  had  recently  developed 
signs  of  phthisis  and  been  sent  to  a  sanatorium,  where  he 
was  progressing  favourably. 

Case   128.     I).    September  14.  1907.    C.  S.,  female. 
twenty-seven.      Eleven    years   ago   had    a   severe   attack   ol 
indigestion  which  lasted  three  months.     Pain  and  vomiting 

alter    all    foods.       For    weeks    lived    On    nothing    but    milk    and 

water.  Was  well  after  that  until  five  years  ago,  when  she 
began  to  suffer  with  pain  of  a  colicky  nature  before  meals, 
which  was  relieved  by  food;  no  vomiting.  Has  losl  1%  stone 
this  year. 

Operation:  Jusl  beyond  the  pylorus  a  well-marked  ulcer 
on  the  anterior  surface  <>i  the  duodenum.  The  gul  was 
puckered  to  a  hard,  cedematous  spot.  Posterior  gastro-enter- 
ostomy.    Recovery.    Senl  by  Dr.  Haigh,  Milnsbridge. 


398  Duodenal  Ulcer 

Report  December,  [908:     ts  perfectly  well;  has  gained  10 

lbs.  Gave  birth  to  twins  in  June  last,  and  had  no  vomiting 
during  the  whole  of  the  pregnancy.  Says  she  has  not  felt 
so  well  for  eight  years. 

Case  129. — D.  September  17,  1907.  T.  W.  A.,  male, 
aged  forty-one.  Quite  well  up  to  three  months  ago.  No 
pain  before  then,  but  occasionally  a  lot  of  flatulence.  Since 
then  has  had  several  attacks  of  pain  lasting  two  or  three 
weeks,  occurring  three  or  four  hours  after  food,  and  always 
accompanied    by   vomiting. 

Operation:  Duodenum  tightly  tucked  backwards;  an  ulcer 
on  its  anterior  surface  surrounded  by  many  adhesions.  Pos- 
terior gastroenterostomy.  Recovery.  Sent  by  Dr.  Cony, 
Scarborough. 

NO  report  can  be  obtained  about  this  patient. 

Case  130. — Duodenal  ulcer  and  gall-stones.  September 
27,  1907.  J.  W.  Q.,  male,  aged  fifty.  Has  had  pain  after 
food  and  occasional  vomiting  for  ten  years.  During  the  last 
three  years  pain  in  the  epigastrium,  which  used  to  come  at 
first  during  the  early  hours  of  the  night;  subsequently  after 
all  meals,  at  an  interval  of  one  to  three  hours.  Food  usually 
relieves,  but  sometimes  flatulence  and  pain  are  very  severe 
until  belching  or  vomiting  relieves  him.  Pain  always  begins 
exactly  in  the  middle  line,  which  is  tender.  Melama  on  one 
occasion  three  weeks  ago. 

Operation:  A  long,  streaky  ulcer,  transverse  to  the  axis 
of  the  duodenum,  with  induration  and  some  contraction. 
Gall-stones.  Posterior  gastroenterostomy.  Cholecystotomy 
— about  30  stones  removed.  Recovery.  Sent  by  Dr.  Haigh, 
Milnsbridge. 

Report  December,  1908:  "Patient  is  perfectly  well.  Has 
gained  16  lbs.  Has  required  no  medical  attention  since  the 
operation,  and  can  take  any  kind  of  food  without  the  least 
discomfort." 

Case  131. — D.  September  27,  1907.  J.  A.,  male,  aged 
thirty-four.  Quite  well  up  to  Christmas,  1906;  then  began 
to  suffer  first  from  vomiting,  and  then  from  pain,  which 
used  to  come  one  to  two  hours  after  food,  lasted  several  hours, 
and    was   relieved   by   vomiting.      For  last   four   months  has 


Detailed  Statement  of  Cases  Operated  Upon  399 

vomited  every  few  days  large  quantities  of  food,  never  blood. 
A  dilated  waving  stomach. 

Operation:  A  large  duodenal  ulcer.  Stomach  dilated,  with 
thickened  walls.  Posterior  gastroenterostomy.  Recovery. 
Sent  by  Dr.  Swindalc,  Clitheroe. 

Report  December,  1908:  Patient's  health  is  excellent; 
has  gained  21  lbs;  not  the  slightest  recurrence  of  symptoms. 

Case  132. — D.  September  29,  1907.  H.,  male,  aged 
forty-one.  Has  suffered  from  attacks  of  pain  some  hours  after 
food  since  childhood;  even  at  that  time  he  found  that  food 
frequently  relieved  the  pain.  Can  remember,  even  at  the 
age  of  seven  or  eight,  having  pain  in  the  stomach,  and  more 
particularly  during  the  night-time,  and  being  taken  into  his 
mother's  bed.  Can  also  remember  when  quite  young  requir- 
ing something  to  eat  between  regular  meals,  and  taking  food 
to  his  bedroom  to  eat  in  the  night,  as  he  found  that  it  relieved 
the  pain.  He  has  had  intervals  of  perfect  freedom  of  varying 
length.  Formerly  these  used  to  be  six  or  nine  months,  but 
for  some  time  past  he  has  not  been  free  from  trouble  for  more 
than  a  few  weeks  at  a  time.  During  the  present  year  he  has 
kept  a  record,  and  this  shews  that  out  of  two  hundred  and 
sixty-seven  days  he  has  only  been  well  about  ninety  days, 
and  these  were  during  the  summer.  Speaking  generally,  he 
is  always  better  in  the  summer  than  in  the  winter.  I'.iin 
comes  on  about  three  hours  after  a  meal.  At  one  time  he 
had  a  good  deal  of  vomiting,  but  this  has  been  less  recently, 
wiih  careful  dieting.     \o  haematemesis  and  no  mel.ena. 

Operation:  A  large  ulcer  just  beyond  the  pylorus  with 
much  scarring:  Main-  adhesions  in  lesser  sac.  Posterior 
gastroenterostomy.  Infolding  of  ulcer.  Recovery.  Sent 
by  Dr.  Martland,  Oldham. 

Report  November,  [908:  "Is  enjoying  good  health  and 
has  done  so  ever  since  operation.  Is  taking  food  of  .ill  kinds 
without  the  slightest  ill  effect  a  thing  he  never  remembers 
to  have  done  before  the  operation." 

CASE    I33.      I).       October    25,     ipo;.       II.     B.,    male. 

thirty-six.    Stomach  symptoms  began  nine  week-  ago.     Pain 

and  flatulence  two  hours  after  food,  followed  by  vomiting. 
Every  tew  days  his  doctor  noticed  th.it  he  became  pallid, 
and  on  examination  melaena  was  found. 


4-00  Duodenal  Ulcer 

Operation:  A  large  ulcer  on  anterior  surface  of  duodenum 
just  beyond  pylorus.  Adhesions  to  under  surface  of  liver. 
Posterior  gastroenterostomy.  Recovery.  Sent  by  Dr.  Nor- 
mington,  Xelson. 

Report  December,  1908:  "Patient  is  very  well.  Has 
gained  at  least  30  lbs.     No  recurrence  of  pain  nor  melaena." 

Cask  134. — D.  October  26,  1907.  Mr.  W.,  aged  twenty- 
nine.  For  the  last  five  or  six  years  has  suffered  pain  two  hours 
after  food,  with  much  flatulence.  There  have  been  scarcely 
any  intervals  of  relief;  no  vomiting  and  no  history  of  melaena. 

Operation:  The  duodenum  was  tightly  tethered  back; 
two  adhesions  to  the  under  surface  of  the  liver  were  divided, 
and  an  indurated  ulcer  was  found  to  lie  between  them.  The 
transverse  colon  was  pulled  down  by  adhesions  to  the  mes- 
entery of  the  small  intestine.  Posterior  gastro-enterostomy. 
Infolding  of  ulcer.     Recovery. 

,  Report:  "This  patient  has  been  seen  at  intervals  up  to 
the  present  time.  He  has  no  pain,  and  the  result  is  very  satis- 
factory." 

Case  135. — D.  October  30, 1907.  Mrs.  \V.,  aged  thirty-six. 
Has  had  indigestion  for  eighteen  months,  gradually  getting 
much  worse.  Pain  occurs  about  two  hours  after  food  and  lasts 
till  next  meal.  Melaena  has  been  detected  on  several  occasions 
since  March.     Has  lost  about  I  stone  in  weight. 

Operation:  An  ulcer  in  the  first  part  of  the  duodenum. 
No  induration.  About  1^2  ins-  beyond  the  pyloric  sphincter 
and  distal  to  the  ulcer  a  circular  narrowing  of  the  duodenum 
appeared  every  now  and  then,  as  though  there  were  a  localised 
hypertrophy    or    spasm    of    the    muscular    fibres.      Posterior 

tro-enterostomy.  Infolding  of  ulcer.  Recovery.  Sent  by 
Dr.  Ellis,  Halifax. 

Report  February,  1909:  "At  first  progress  was  slow,  but 
during  the  last  three  months  has  gained  weight  rapidly,  and 
is  now  very  well  indeed." 

Case  136. — D.  November  1,  1907.  A.  B.,  male,  aged 
thirty-seven.  Stomach  symptoms  for  years  and  occasional 
vomiting.  Pain  comes  two  hours  after  food,  and  is  relieved 
by  vomiting.  The  last  four  months  vomiting  has  been  per- 
sistent.    A  dilated   waving  stomach. 


Detailed  Statement  of  Cases  Operated  Upon  401 

Operation:  A  large  mass  of  induration  in  duodenum; 
stomach  dilated  and'thickened.  Posterior  gastroenterostomy. 
Sent  by  Dr.  Friend,  Leeds.     Transferred  from  Dr.  Churton. 

Report  December,  1908:  "Eats  any  food;  is  troubled  with 
slight  flatulence  and  some  constipation;  no  vomiting.  Has 
gained  over  a  stone  in  weight. 

Case  137. — G.  &  D.  November  15,  1907.  Mr.  H.,  aged 
fifty-five.  Pain  after  food  for  several  years.  The  pain  is 
situated  in  left  hypochondriac  region  and  occurs  one  and 
one-half  hours  after  food.  There  has  been  no  vomiting  and 
no  melaena.  A  drink  of  water  frequently  relieves  pain.  Has 
lost  I  stone  during  the  last  three  months. 

Operation:  A  large  indurated  ulcer  on  the  lesser  curvature 
near  cardia.  In  the  first  part  of  the  duodenum  an  ulcer 
adherent  to  enlarged  glands  in  gastro-hepatic  omentum. 
Infolding  of  duodenal  ulcer.  Posterior  gastroenterostomy. 
Recovery.     Sent  by  Dr.  Molloy,  Blackpool. 

Report  November,  1908:  "The  operation  has  been  an  un- 
qualified success.  Mr.  H.  has  now  a  healthy  colour  and  com- 
plexion. He  can  take  all  kinds  of  food,  but  has  to  be  careful 
not  to  take  too  much  at  a  time.    Is  now  about  normal  weight." 

Case  138. — D.  December  12,  1907.  Mr.  L.,  aged  thirty- 
one.  Three  years  ago  began  to  suffer  from  pain  in  the  cpi- 
rium,  occurring  one  and  one-half  to  two  hours  after  food, 
and  lasting  until  the  next  meal,  when  it  became  easier.  His 
meals  have  been  extremely  irregular.  He  had  his  breakfast 
very  early  and  went  straighl  away  to  work,  often  giving  him- 
self only  a  few  minutes'  interval  for  lunch,  and  occasionally 
taking  very  little  food  until  the  evening,  when  he  had  a  very 
large  meal  and  went  to  bed.  There  have  been  some  short 
intervals  of  relief  from  pain  up  to  eighteen  months  ago,  when 
he  became  much  worse,  pain  occurring  after  everj  meal, 
although  food  still  relieved  it  to  some  extent.  There  has  been 
no  vomiting.  Three  days  before  admission  .1  severe  attack  of 
melaena,  which  lasted  for  two  days.  On  admission  the  patient 
was  blanched  and  weak,  although  the  melaena  had  ceased. 

Operation:    Stomach  not  dilated.     A  hard  ulcer  about  the 

size  ol  .1  pe.i  on  posterior  surface  of  the  duodenum  just  beyond 

the  pylorus.     Posterior  gastro-enterostomy.     I  leer  infolded 


402  Duodenal  Ulcer 

by  suture  from  posterior  aspect  through  opening  in  lesser  sac. 
Pylorus  closed  by  interrupted  sutures.  Recovery.  Sent  by 
Dr.  Beaman,  Normanton. 

Seen  July,  1909:  "Has  gained  considerably  in  weight; 
has  no  indigestion;  health  good." 

Case  139. — D.  January  8,  1908.  Mr.  M.,  aged  fifty-one. 
Pain  occurring  after  food  for  the  last  six  months.  Sometimes 
immediately  after,  usually  two  to  three  hours  after  a  meal. 
Much  flatulence.  No  vomiting,  no  melsena.  Has  lost  nearly 
1  }/2  stone.     Stomach  large;  no  food  stasis. 

Operation:  A  large  stomach,  pylorus  narrow.  An  ulcer 
on  the  anterior  surface  of  duodenum  just  beyond  pylorus. 
Posterior  gastroenterostomy.  Infolding  of  ulcer.  Recovery. 
Sent  by  Dr.  Wood,  Wakefield. 

Report  January,  1909:  "Present  condition  very  satis- 
factory. Has  gained  weight.  No  recurrence  of  pain  nor 
vomiting;  has  been  operated  on  for  double  empyema  since 
his  gastro-enterostomy,  but  is  now  quite  well." 

Case  140. — D.  January  10,  1908.  J.  C,  male,  aged  fifty. 
Pain  two  to  three  hours  after  food  for  the  last  seventeen 
or  eighteen  years;  relieved  by  food.     No  haemorrhage. 

Operation:  A  large  ulcer  just  beyond  pylorus.  Posterior 
gastro-enterostomy.  Infolding  of  ulcer.  Recovery.  Sent 
by  Dr.  Woodcock,  Leeds. 

No  report  can  be  obtained. 

Case  141. — G.  &  D.  January  10,  1908.  M.  G.,  female, 
aged  fifty-four.  Has  had  symptoms  for  twenty  years.  Pain 
coming  an  hour  after  food,  with  much  vomiting;  now  has 
an  enormously  dilated,  waving  stomach;  daily  vomiting  of 
large  quantities.     Great  emaciation. 

Operation:  Hard,  cicatricial  mass  at  the  pylorus.  At  the 
upper  border  of  the  first  part  of  the  duodenum  a  hard  scar. 
At  the  inferior  border  a  curious  pouching  of  the  duodenal 
wall.  Posterior  gastro-enterostomy.  Recovery.  Sent  by  Dr. 
Harvey,  Swinton. 

Report  January,  1909:  "Enjoys  excellent  health;  has 
gained  3  stone  6  lbs.  Has  had  no  recurrence  of  pain.-  Says 
she  can  eat  anything.  Mrs.  G.'s  return  to  health  is  the  talk 
of  the  countryside." 


Detailed  Statement  of  Cases  Operated  Upon  403 

Caxse  142. — D.  January  17,  1908.  Mr.  M.,  aged  sixty- 
two.  Pain  occurring  two  to  three  hours  after  food  for  a 
number  of  years,  with  intervals  of  relief.  During  the  last 
twelve  months  symptoms  have  been  more  acute;  much 
flatulence.  Pain  frequently  severe  at  night  and  is  relieved 
by  food.    Occasional  vomiting.    Xo  hsematemesis  nor  melaena. 

Operation:  An  ulcer  in  the  first  part  of  the  duodenum. 
Posterior  gastroenterostomy.  Infolding  of  ulcer.  Recovery. 
Patient  sent  by  Dr.  Rheinhart  Anderson,  Southport. 

Report  January,  1909:  "Present  condition  good.  Has 
gained  24  lbs.  Sleeps  well;  eats  anything.  This  is  a  case 
in  which  the  benefit  of  the  operation  has  been  very  great. 
He  looks  and  feels  another  man." 

Case  143. — D.  January  17,  1908.  C.  W.,  male,  aged 
twenty-six.  Eight  years  ago  began  to  have  pain  in  upper 
abdomen  after  going  to  bed.  This  was  usually  accompanied 
by  a  feeling  of  great  distension;  later  pain  began  to  come  in 
the  daytime,  one  and  one-half  hours  after  food.  Since  last 
August  has  had  both  ha?matemesis  and  melaena. 

Operation:  Two  large  scars  in  first  portion  of  duodenum. 
Posterior  gastroenterostomy.  Recovery.  Sent  by  Dr.  Fryer, 
Barnsley. 

Report  January,  1909:  Feels  well  in  himself  and  is  able 
to  work  without  any  trouble.  Has  a  good  appetite;  "eats 
nearly  anything."     "  Is  a  vegetarian."     Xo  pain  nor  vomiting. 

Case  144. — D.  January  19,  1908.  Dr.  \\\,  male,  aged 
thirty-eight.  Since  the  age  of  twenty  has  suffered  from 
attacks  of  indigestion.  Pain  occurring  two  hours  after  food 
and  lasting  until  next  meal.  In  February,  1906,  a  very  severe 
attack;  great  pain,  which  was  worse  a1  night.  December, 
[906,  melaena  lasting  for  four  days.  Since  then  has  had  very 
little  relief  from  pain,  which  is  always  worse  in  cold  weather. 
There  has  been  no  vomiting. 

Operation:  Stomach  not  dilated.  In  the  first  part  of  the 
duodenum  puckered  scars  of  five  separate  ulcers.  Strong 
adhesion  to  the  neck  of  gall-bladder.  The  firsl  part  of  the 
duodenum  was  enveloped  by  thin  adhesions  which  were  sepa- 
rated by  gauze  stripping.  Posterior  gastro-enterostomy.  In- 
folding of  ulcer.     Recovery.     Senl  by  Dr.  Crowley,  Bradford. 


404.  Duodenal  Ulcer 

Report,  letter  from  patient,  February  15,  1909:  "Am 
glad  to  be  able  to  tell  you  that  at  least  I  am  beginning  to 
feel  the  benefits  of  operation.  Feeling  really  well  again  and 
getting  my  spring  back.  I  have  to  exercise  a  little  care  about 
dieting,  but  can  take  most  reasonable  things  now,  and  hardly 
ever  feel  the  least  pain." 

Case  145. — D.  January  19,  1908:  Mr.  B.,  aged  fifty. 
Attacks  of  severe  epigastric  pain  for  several  years,  coming 
on  two  to  four  hours  after  food,  and  situated  midway  between 
umbilicus  and  ensiform;  almost  always  relieved  by  food. 
Intervals  of  complete  relief  from  pain — longest  about  five 
months;  recently  intervals  shorter.  No  vomiting,  no  melaena. 
Has  lost  weight  recently. 

Operation:  Stomach  slightly  dilated.  Duodenum  tightly 
tethered  back  beneath  liver.  An  indurated  ulcer  just  beyond 
pylorus.  Posterior  gastro-enterostomy.  Infolding  of  ulcer. 
Recovery.     Sent  by  Dr.   Buckley,   Nottingham. 

Report  January,  1909:  "Condition  very  satisfactory; 
gained  about  13  lbs.  I  have  not  had  occasion  to  attend  Mr. 
B.  since  the  operation.  Have  only  seen  him  once,  and  I 
consider  the  result  most  satisfactory." 

Case  146. — G.  &  D.  January  22,  1908.  Mr.  F.,  aged 
forty-four.  Symptoms  for  eight  years.  At  first  pain  occurred 
soon  after  food.  Recently  has  occurred  mainly  at  night,  and 
three  to  four  hours  after  food.  During  the  last  eighteen 
months  has  had  frequent  vomiting,  often  of  large  quantities. 
Has  never  had  haematemesis.  Recently  food  has  often  relieved 
pain;  has  lost  2  stone  in  weight.  A  large,  actively  contract- 
ing stomach,  much  food  stasis. 

Operation:  Stomach  much  dilated.  In  the  prepyloric 
region  scar  of  old  ulceration.  In  the  first  part  of  the  duo- 
denum a  hard,  indurated  area  size  of  a  Barcelona  nut,  evi- 
dently long-standing  ulceration,  to  which  the  omentum  was 
adherent.  Posterior  gastro-enterostomy ;  first  part  of  the 
duodenum  infolded.    Recovery.    Sent  by  Dr.  Johnson,  Altofts. 

Report    January,     1909:       "Condition    very    good.      Has 

tied  weight;  doing  his  work  and  attending  public  dinners, 
etc.      Result  everything  that  could  be  desired." 

Case   [47. — G.  &  D.    January  25.  1908.    J.  R.,  male,  aged 


Detailed  Statement  of  Cases  Operated  Upon  405 

fifty-eight.  For  twenty-two  years  pain  after  food  and  occa- 
sional vomiting.  At  first  pain  used  to  come  about  one-half 
hour  after  food,  but  latterly  has  been  noticed  before  food, 
and  food  has  relieved  it.  Lately  there  has  been  melsena  on 
several  occasions. 

Operation:  The  abdominal  cavity  was  opened  with  diffi- 
culty on  account  of  the  enormous  number  of  adhesions.  The 
omentum  covered  the  stomach  completely,  having  been  entirely 
turned  over.  Separation  of  adhesions  very  tedious  and  diffi- 
cult. There  were  scars  of  old  ulcers  on  the  lesser  curvature. 
one  of  which  had  no  doubt  perforated  on  a  previous  occasion. 
In  the  duodenum  a  recent  ulcer.  Posterior  gastroenter- 
ostomy.    Recovery.     Sent  by  Dr.  Marsh,  Long  Preston. 

Report  January,  1909:  "Present  condition  very  good. 
Is  perfectly  well;  has  gained  about  2  stone." 

Case  148. — D.  January  31,  1908.  H.  G.,  male,  aged 
forty-two.  For  seventeen  years  has  suffered  on  and  off  from 
indigestion.  Has  always  been  worse  in  the  winter  and  better 
in  the  summer.  Five  or  six  years  ago  began  to  be  much 
worse.  Pain  comes  two  or  three  hours  after  food.  Some- 
times, especially  after  a  heavy  meal,  pain  comes  four  hours 
after  food;  is  always  relieved  by  food.  For  the  last  two 
years  has  had  vomiting.    Has  now  a  dilated,  waving  stomach. 

Operation:  A  large,  indurated  ulcer  just  beyond  pylorus. 
I'li-terior  gastroenterostomy.  Recovery.  Sent  by  Dr. 
Richardson,  Leeds. 

Report  January,  1909:  "  Is  in  good  health.  Weight  about 
the  same.  He  has  no  pain.  Can  eat  anything  and  suffers 
no  indigestion.     Feels  quite  well  and  strong." 

Case  149.- — D.  February  7,  1908.  Mr.  C.  Fourteen 
years'  history  of  attacks  of  epigastric  pain,  coming  on  two 
to  three  hours  after  food.  Frequently  relieved  byfood.  Vom- 
iting occurs  soon  after  the  onset  of  pain.  There  have  been 
intervals  of  complete  relief,  but  latterly  these  have  become 
shorter  and  less  frequent.  There  has  been  neither  haemat- 
emesis  nor  melaena. 

Operation:  A  large  indurated  ulcer  on  the  anterior  surface 
of  the  duodenum,  '  1  inch  beyond  the  pylorus;  omental  ad- 
hesions. Posterior  gastro-enterostomy.  Infolding  ol  ulcer. 
Recovery.    Senl  by  Dr.  Fawsitt,  Oldham. 


406  Duodenal  Ulcer 

Report  January,  1909:  "Present  condition  very  good. 
Had  gained  10^  lbs.  by  November.  Is  very  well  and  can  take 
any  kind  of  food  in  moderation.  Since  the  operation  he  has 
had  to  take  aperients  nearly  every  day,  which  was  not  the 
case  previously." 

CASE  150. — D.  February  8,  1908.  J.  S.,  male,  aged 
sixty-three.  Two  and  one-quarter  years  ago  began  to  have 
pain  after  food,  generally  about  three  hours  after.  It  lasted 
one  to  two  hours  and  was  relieved  by  next  meal.  Summer 
following  onset  he  had  no  pain  at  all.  It  returned,  however, 
in  October, 'and  has  lasted  almost  ever  since.     Lost  1^2  stone. 

Operation:  A  large  duodenal  ulcer,  equal  in  size  to  a 
shilling,  with  adhesions  to  the  liver.  Posterior  gastroenter- 
ostomy.    Recovery.     Sent  by  Dr.  Kirke-White. 

Report  January,  1909:  "Can  eat  all  kinds  of  food  without 
any  pain;  appetite  good;  feels  better  than  he  has  done  for 
years;  has  gained  about  16  lbs." 

Case  151. — D.  February  8,  1908.  T.  D.,  male,  aged 
forty-three.  Eight  years  ago  began  to  have  pain  about  one 
and  one-half  hours  after  food,  relieved  by  more  food  or  by 
vomiting.  During  the  last  five  years  has  had  signs  of  pyloric 
obstruction  with  frequent  vomiting;  has  now  a  dilated, 
waving  stomach. 

Operation:  A  large  duodenal  ulcer  adherent  to  liver. 
Posterior  gastroenterostomy.  Recovery.  Sent  by  Dr. 
Stephenson. 

Report  January,  1909:  "Has  had  no  trouble  since  opera- 
tion. Has  gained  3  stone  10  lbs.  in  weight,  and  is  I  stone 
heavier  than  he  ever  was  before." 

Case  152. — G.  &  D.  February  10,  1908.  Mr.  M.,  aged 
thirty-eight.  Pain  one  and  one-half  to  two  hours  after  food 
for  several  years.  Food  often  temporarily  relieves,  the  pain. 
Has  frequent  vomiting.  There  were  intervals  of  relief  from 
pain  until  two  years  ago.  Since  that  time  pain  has  been 
much  worse  and  almost  constant.  Has  lost  weight  con- 
siderably. Eight  weeks  ago  severe  hsematemesis.  Is  now 
very  anaemic. 

Operation:  A  large  ulcer  extending  along  the  lesser  cur- 
vature  of    the    stomach    for   one    inch    into    the    duodenum. 


Detailed  Statement  of  Cases  Operated  Upon  407 

Firmly  adherent  to  the  liver  above  and  to  the  upper  border 
of  the  pancreas  behind.  Numerous  adhesions  to  the  anterior 
abdominal  wall,  probably  the  result  of  an  old  perforation. 
Posterior  gastroenterostomy  by  Mayo's  method.  Recovery. 
Sent  by  Dr.  Horsfall,  Bedale. 

Report  January,  1909:  "  Is  in  fairly  good  health,  although 
he  is  still  rather  anaemic.  Has  gained  1%  stone  in  weight. 
Has  really  better  health  than  he  has  known  for  twenty  years, 
and  is  intensely  grateful." 

Case  153. — D.  February  13,  1908.  Mr.  C,  aged  forty- 
five.  Twenty  years'  history  of  indigestion  and  heart-burn. 
Never  very  severe,  but  frequently  recurring.  Seventeen 
years  ago  melsena.  A  second  attack  noticed  in  October, 
1906,  but  probably  there  were  several  in  the  interval.  In  the 
summer  of  1907  an  extremely  severe  attack  of  haematemesis 
and  melaena.  Another  on  January  1,  1908,  and  another  ten 
days  later.    A  thin,  very  anaemic  man. 

Operation:  A  puckered  ulcer  the  size  of  a  threepenny  piece 
on  the  anterior  surface  of  the  first  part  of  the  duodenum,  with 
broad  adhesions  to  gall-bladder.  The  ulcer  was  infolded  and 
posterior  gastroenterostomy  performed.  Recovery.  Sent 
by  Ur.   Martland,  Oldham. 

Report  January,  1909:  "Condition  quite  satisfactory. 
Since  the  operation  there  has  been  no  haemorrhage  and  he  has 
regained  his  normal  weight  and  colour,  and  is  quite  well  and 
strong." 

Case  154. — D.  February  24,  1008.  G.  R.  W.,  male,  aged 
twenty-four.  Five  years  ago  began  to  suffer  from  pain  in 
i-tiiinn,  coming  on  two  hours  after  food.  He  did  not 
vomit  at  this  time;  food  sometimes  relieved  pain,  which  was 
not  severe  enough  to  make  him  seek  medical  treatment. 
Was  free  from  symptoms  for  a  time,  bul  at  Christmas,  1906, 
pain  recurred  about  two  hours  after  food,  and  lie  began  to 
vomit.  Gastric  lavage  and  milk  diet  relieved  him.  but  a 
fortnighl  ago  the  pain  returned,  and  he  has  had  frequent 
vomiting  of  large  quantities  of  sour  material. 

Operation:  A  large  nicer  in  the  duodenum  immediately 
beyond  pylorus.  Some  induration  had  extended  ^li^htly  to 
the  stomach  side  of  the  pylorus.     Posterior  gastro-enteros- 


408  Duodenal  Ulcer 

tomy.     Infolding  of  ulcer.    Recovery.    Convalescence  slightly 

retarded  by  left  pleural  effusion.  Sent  by  Dr.  J.  Lambert, 
Parsley. 

Report  January,  1909:  "Looks  well,  eats  well,  has  worked 
regularly  for  the  last  eight  months.  Has  steadily  regained 
his  old  weight." 

Case  155. — D.  February  12,  1908.  C.  R.,  male,  aged 
forty-two.  For  ten  years  epigastric  pain,  coming  on  about 
one  hour  after  food.  At  first  did  not  vomit.  Intervals  of 
relief,  particularly  during  the  summer.  Five  or  six  years  ago 
pain  became  more  severe  and  vomiting  occurred,  mainly  of 
mucus,  with  a  little  food.  Vomiting  usually  relieved  pain. 
Has  lost  6  lbs.  during  the  last  two  years.  No  history  of 
hsematemesis  nor  melaena. 

Operation:  Well-marked  ulcer  just  beyond  pylorus.  Pos- 
terior gastro-enterostomy.  Infolding  of  ulcer.  Recovery. 
Sent  by  Dr.  Cowan,  Malvern. 

Report  January,  1909:  "After  return  home  was  laid  up 
for  some  time  with  phlebitis  in  veins  of  left  leg.  Has  gained 
in  weight.  No  vomiting.  Occasional  flatulence."  Was  seen 
by  ourselves  at  end  of  1908,  and  at  that  time  was  extremely 
well  as  regards  his  gastric  trouble,  but  was  complaining  of 
symptoms  suggestive  of  renal  calculus. 

Case  156. — D.  March  6,  1908.  H.  L.,  male,  aged  thirty- 
six.  Nine  or  ten  years  ago  suffered  from  attacks  of  colic, 
followed  by  vomiting,  which  relieved  his  pain.  Was  operated 
upon  by  another  surgeon  and  the  appendix  removed.  Five 
months  later  was  seen  by  myself  and  a  diagnosis  of  duodenal 
ulcer  made.  Operation  advised  and  refused.  From  that 
time  to  this  has  had  frequent  attacks  of  pain,  occurring  some 
hours  after  food  and  during  the  night,  frequently  followed  by 
vomiting,  which  relieves  the  pain.  Has  employed  gastric 
lavage  with  benefit. 

Operation:  A  large,  puckered  ulcer  x/i  incn  beyond  pylorus. 
At  one  point  it  looked  as  though  perforation  was  imminent. 
Posterior  gastro-enterostomy.  Infolding  of  ulcer.  Recovery. 
Sent  by  Dr.  Cameron,  Dewsbury. 

Report  January,  1909:  Is  in  perfect  health;  never  felt 
better  in  his  life;  has  gained  I  stone  12  lbs.  since  his  operation. 


Detailed  Statement  of  Cases  Operated  Upon  409 

Case  157. — D.  March  7,  1908.  A.  F.,  male,  aged  thirty- 
one.  Five  years  ago  began  to  have  pain,  coming  on  two  hours 
after  food.  Pain  usually  lasted  for  two  or  three  hours  unless 
relieved  by  vomiting.  Attacks  of  pain  recurred,  with  varying 
intervals  of  relief,  up  to  the  present.  Three  months  ago 
an  attack  of  haematemesis  and  melsena.  Since  that  time  pain 
has  been  particularly  severe. 

Operation:  A  large,  star-shaped  scar  just  beyond  the 
pylorus.  Posterior  gastroenterostomy.  Infolding  of  ulcer. 
Recovery.     Sent  by  Dr.  Ward,  Ferrybridge. 

Report  January,  1909:  Is  very  well;  has  gained  10  lbs. 
in  weight.  No  recurrence  of  pain  nor  vomiting;  follows  his 
employment  regularly. 

Case  158. — D.  March  9,  1908.  Mr.  H.,  aged  twenty- 
eight.  Pain  two  to  three  hours  after  food  for  twelve  years. 
Always  relieved  by  food.  Attacks  have  gradually  increased 
in  frequency  and  severity.  During  the  last  three  years  has 
never  been  free  for  more  than  six  weeks.  During  the  last 
twelve  months  has  had  nausea,  but  no  actual  vomiting.  No 
melaena.     In  the  last  three  months  has  lost  2  stone  in  weight. 

Operation:  A  large  ulcer  on  the  anterior  surface  of  the 
duodenum,  just  beyond  the  pylorus,  hard  and  puckered  in 
the  centre.  Posterior  gastroenterostomy.  Infolding  of  ulcer. 
Recovery.     Sent  by  Dr.  Mason,  Boston. 

Report  January,  1909:  Has  occasional  pain  in  epigastrium 
and  under  right  costal  margin;  chiefly  in  the  early  hours  ol 
the  morning.  His  chief  complaint  is  that  he  cannot  eat  a 
good  meal  without  discomfort,  sometimes  amounting  to  pain 
afterwards.  Pain  is  all  over  the  abdomen  and  in  the  loins. 
Is  slightly  constipated;  tongue  rather  furred  and  Micky. 
Motion-,  rather  lighl   coloured. 

Report  from  patient  September,  [909:  "In  response  to 
your  enquiry  I  am  pleased  to  be  able  to  say  without  any 
reservation  whatever  that  I  am  quite  well.  I  have  had  no 
trouble  at  all  since  March  and  I  can  now  ea1  anything." 

Case  159. — G.&D.  March  10.  [908.  Rev.  A.,  aged  fifty  - 
five.  For  rather  more  than  two  years  lias  suffered  a  good 
deal  from  abdominal  pain.  As  far  as  he  can  remember  al 
t'li^!.   the  pain  was  in   the  epigastric  and   umbilical   regions, 


410  Duodenal  Ulcer 

but  latterly  has  been  more  localised  to  the  right  hypochon- 
drium.  There  were  periods  when  the  pain  recurred  with 
great  regularity,  both  by  day  and  night,  and  he  could  never 
go  longer  than  about  two  to  two  and  one-half  hours  with- 
out having  something  to  eat  or  drink.  Most  frequently  hot 
water  has  given  him  relief,  and  at  meal-times  he  has  thought 
that  a  glass  of  sherry  or  hot  whisky  and  water  has  relieved 
him.  All  through  last  winter,  for  many  weeks  together,  had 
to  get  up  in  the  night  and  boil  water  and  make  a  cup  of 
cocoa.  There  have  been  occasional  periods  of  a  day  or  two 
when  he  has  been  quite  free  from  pain.  Has  often  relieved 
himself  by  eating  mouthfuls  of  Cheddar  cheese.  Extra  men- 
tal strain  or  anxiety  has  always  aggravated  the  pain  and 
holidays  have  always  relieved..  The  urine  contained  some 
albumin,  5  per  cent.  (Esbach),  and  operation  was  postponed 
for  a  few  months.  In  the  interval  pain  was  extremely  severe, 
and  he  was  re-admitted  in  March,  1908. 

Operation:  Large  quantities  of  omental  and  subperitoneal 
fat.  Adhesions  between  anterior  surface  of  first  part  of 
the  duodenum  and  neck  of  gall-bladder.  An  indurated  ulcer 
on  the  posterior  surface.  Extensive  adhesions  between  the 
posterior  surface  of  the  stomach  and  pancreas,  making  pos- 
terior gastro-enterostomy  impracticable.  Anterior  gastro- 
enterostomy wras  performed,  with  lateral  anastomosis  between 
afferent  and  efferent  limbs.  Recovery.  Sent  by  Dr.  Basil 
Housman,  Stockport. 

Report  January,  1909:  "Is  steadily  improving;  has  lost 
much  superficial  fat  and  looks  much  better.  Has  occasional 
pain  alter  extra  exertion  or  worry,  but  this  is  not  so  severe  as 
formerly  and  occurs  at  longer  intervals.  He  is  convinced  of 
his  steady  improvement." 

Case  160. — D.  March  19,  1908.  Mr.  S.,  aged  sixty-one. 
From  the  age  of  twenty  to  forty  suffered  from  repeated 
attacks  of  pain  in  the  pit  of  the  stomach,  striking  through 
to  the  back,  coming  on  about  two  hours  after  meals  and 
always  reliev-ed  by  taking  food.  This  pain  occurred  both  day 
and  night,  with  occasional  intervals  of  freedom,  perhaps 
lasting  several  months.  Was  diagnosed  as  nervous  dyspepsia. 
Between  forty  and  fifty  the  attacks  of  pain  were  most  marked 


Detailed  Statement  of  Cases  Operated  Upon  41 1 

at  night,  and  were  relieved  by  large  doses  of  carbonate  of 
soda.  After  fifty  years  of  age  an  interval  of  relief  for  two  or 
three  years,  and  he  gained  nearly  2  stone  in  weight;  then  the 
pain  returned,  and  has  been  accompanied  by  vomiting,  which 
has  usually  relieved  the  pain  and  preceded  a  period  of  com- 
parative comfort.  During  the  last  six  weeks  has  been  wash- 
ing out  stomach,  with  considerable  relief.  Slight  gastric 
dilatation. 

Operation:  A  large,  indurated  ulcer  on  anterior  surface 
of  first  part  of  duodenum,  producing  slight  stenosis.  The 
central  part  was  hard,  white,  and  raised  above  the  surrounding 
part  like  a  keloid.  Posterior  gastroenterostomy.  Infolding 
of  ulcer.     Recovery.    Sent  by  Dr.  H.  Edgecombe,  Harrogate. 

Report  January,  1909:  Is  quite  another  man.  Feels 
better  than  he  has  done  for  years.  Can  eat  anything  and 
everything  without  discomfort.  Bowels^ quite  regular.  Has 
gained  11  lbs.  in  weight. 

Case  161. — D.  March  20,  1908.  Mrs.  H.,  aged  sixty. 
For  years  has  had  pain  after  food  and  flatulence.  Since 
November  last  has  suffered  from  frequent  vomiting,  occurring 
almost  immediately  after  taking  food.  The  vomit  has  alwa> rs 
been  small  in  quantity,  and  just  the  food  which  has  been 
taken,  with  some  mucus.  Has  lost  weight  rapidly.  There 
has  been  no  hsematemesi>.  At  tempts  at  gastric  lavage  were 
not  satisfactory,  and  it  was  doubtful  whether  the  tube  was 
really  passed  beyond  the  cardiac  orifice. 

Operation:  Stomach  was  small;  in  the  first  part  of  the 
duodenum  was  the  stellate  scar  of  an  ulcer.  Gall-bladder  very 
small  and  shrivelled,  and  tightly  embracing  two  calculi. 
Posterior  gastroenterostomy.  Infolding  of  ulcer.  Cholecys- 
tectomy. Recovery.  Sent  by  Dr.  Brantley  Taylor,  Hems- 
worth. 

This  patient  returned  to  the  Nursing  Home  July,  1908. 
Since  going  home  had  been  better  and  gained  weight,  but 
continued  to  regurgitate  a  small  quantity  of  food  each  eve- 
ning. A'-ray  examination  after  .1  bismuth  meal  -hewed  that 
the  whole  of  the  bismuth  was  retained  in  the  oesophagus,  and 
caused  a  shadow  considerably  broader  at  the  lower  than  the 
upper  end,  and  abruptly  rounded  off  at   the  cardiac  orifice. 


412  Duodenal  Ulcer 

Every  few  seconds  a  ring-like  contraction  travelled  down  the 
oesophagus.  At  the  end  of  half  an  hour  these  peristaltic 
waves  were  clearly  visible,  and  little,  if  any,  of  the  bismuth 
had  passed  into  the  stomach.  A  diagnosis  of  cardiospasm 
was  made.  The  cardiac  crifice  of  the  oesophagus  was  dilated 
by  bougies  passed  along  a  silk  guide,  and  this  treatment  is 
still  being  carried  out,  with  some  improvement. 

Case  162. — D.  March  27,  1908.  R.  B.,  male,  aged  fifty- 
five. 

Operation:  A  large,  thickened  ulcer  on  anterior  wall  of  the 
duodenum  just  beyond  pylorus.  The  duodenum  was  dis- 
tinctly stenosed  for  about  %  inch.  Posterior  gastroenteros- 
tomy. Ulcer  infolded.  Recovery.  Sent  by  Dr.  Swindale, 
Clitheroe. 

Report  January,  1909:  Says  he  has  felt  better  since  his 
operation  than  he  has  for  the  last  ten  years.  Has  gained  six 
pounds  in  weight  and  is  in  excellent  health. 

Case  163. — D.  April  4,  1908.  Mr.  N.,  aged  forty-nine. 
For  forty  years  has  been  subject  to  attacks  of  epigastric  pain 
occurring  two  to  three  hours  after  food,  with  intervals  of 
complete  relief.  Recently  attacks  have  been  more  frequent 
and  severe  and  accompanied  by  vomiting.  Three  years  ago 
a  very  severe  attack,  diagnosed  as  appendicitis.  There  has 
been  no  haematemesis  nor  melaena,  nor  has  jaundice  been 
noted  at  any   time. 

Operation:  Stomach  a  little  dilated.  The  duodenum  and 
neck  of  gall-bladder  were  intimately  adherent,  and  by  careful 
dissection  a  distinct,  tube-like  fistula,  \  inch  in  length,  was 
defined  between  them.  The  gall-bladder  was  full  of  calculi, 
some  of  which  were  impacted  in  the  cystic  duct.  The  fistula 
was  divided  and  the  duodenum  closed.  Posterior  gastro- 
enterostomy. Cholecystectomy  performed  with  considerable 
difficulty.  Recovery.  Sent  by  Dr.  Nesbitt,  Sutton  in  Ash- 
field. 

Report  January,  1909:  "Present  condition  very  satis- 
factory; with  the  exception  of  an  attack  of  pain  and  vomit- 
ing on  the  1st  of  June,  has  had  no  pain  since  operation.  Has 
gained  considerably  in  wreight."  Was  seen  by  myself  in 
March  and  had  no  trouble. 


Detailed  Statement  of  Cases  Operated  Upon  413 

Case  164. — D.  April  8,  1908.  Mr.  B.,  aged  twenty-one. 
For  four  years  has  had  pain  and  discomfort  two  hours  after 
food,  with  flatulence  and  acid  eructations.  The  pain  is  oc- 
casionally, but  not  always,  relieved  by  food.  Occasional 
vomiting  during  last  three  or  four  months.  During  this  time 
he  has  never  really  been  free  from  pain.  No  haematemesis 
and  no  melaena. 

Operation:  Duodenum  tightly  tethered  back  beneath  liyer. 
A  large,  excavated  ulcer  on  the  upper  aspect  of  the  first  part 
of  the  duodenum,  I  inch  beyond  pylorus.  Posterior  gastro- 
enterostomy. Infolding  of  ulcer.  Recovery.  Sent  by  Dr. 
Tawse,  Whitehaven. 

Report  January,  1909:  Condition  has  been  excellent  ever 
since  operation,  and  there  have  been  no  symptoms  of  any  sort, 
and  he  has  obviously  gained  in  weight. 

Case  165. — D.  April  10,  1908.  E.  M.  A.,  female,  aged 
twenty-nine.  At  the  age  of  eighteen  suffered  from  pain  in 
the  stomach  directly  after  food.  No  vomiting.  Four  years 
ago  pain  began  to  come  three  hours  after  food  and  she  had 
two  attacks  of  haematemesis.  Since  that  time  has  not  worked. 
Now  has  pain  about  two  hours  after  food,  frequently  severe 
at  night.  Relieved  by  food  or  milk.  Six  weeks  ago  a  severe 
attack  of  haematemesis. 

Operation:  A  well-defined  star-shaped  scar  just  beyond 
the  pylorus.  Posterior  gastroenterostomy.  Infolding  of  ulcer. 
Recovery. 

Patient  cannot  be  traced. 

Case  166. — D.  April  18,  1908.  M.  A.  B.,  female,  aged 
thirty-eight.  For  man\-  years  has  suffered  from  indigestion. 
No  severe  pain  until  four  or  five  years  ago,  when  she  began  to 
have  attacks  of  severe  pain  in  epigastric  region,  spreading 
all  over  the  abdomen  and  accompanied  by  severe  vomiting. 
The  attack-  have  occurred  1  \er\  two  to  three  months  and  arc 
rather  more  frequent  in  the  winter.  Has  never  had  jaundice. 
Has  losl  aboul   i^stonein  three  years. 

Operation:  A  large  scar  iti^t  beyond  pylorus.  A  firm 
adhesion  passed  diagonally  across  the  firsl  part  ol  the  duo- 
denum, constricting  it.  Posterior  gastro-enterostomy.  Ulcer 
infolded.     Recovery.    Senl  by  Dr.  R.  II.  Trotter,  Ilolmiirth. 


414  Duodenal  Ulcer 

Report  January,  1909:  "Patient  is  in  good  health;  has 
gained  weight;  no  recurrence  of  symptoms;  appears  to  have 
been  cured  by  the  operation." 

Case  167. — D.  June  11,  1908.  T.  C,  male,  aged  forty- 
one.  Pain  on  and  off  for  twenty  years;  occurs  some  hours 
after  food  and  is  relieved  by  taking  food.  Has  frequently 
vomited,  but  has  never  noticed  blood.  Eight  years  ago  an 
attack  of  melsena.  Recently  pain  has  been  almost  continuous 
and  he  has  lost  I  stone  in  weight. 

Operation:  Duodenum  shewed  two  scars:  one  small, 
immediately  beyond  the  pylorus;  a  second,  larger  one,  I 
inch  from  pylorus,  with  much  puckering  and  induration. 
Posterior  gastroenterostomy.     Infolding  of  ulcer.     Recovery. 

Report  from  patient  January,  1909:  "I  have  not  had  any 
pain  nor  sickness  since  the  operation,  and  have  always  been 
ready  for  my  food.  I  began  work  in  September  and  think 
I  am  going  on  all  right." 

Case  168. — D.  June  13,  1908.  J.  D.,  male,  aged  fifty. 
Patient  complained  of  abdominal  pain  and  vomiting.  He  had 
had  this  pain  for  ten  years;  it  was  heavy  and  dull,  situated 
in  the  epigastrium,  coming  on  some  time  after  meals,  and 
relieved  by  vomiting. 

Operation:  A  well-marked  ulcer  on  the  anterior  surface  of 
the  duodenum,  with  much  puckering  and  many  adhesions. 
The  mesocolon  was  adherent  to  the  posterior  surface  of  the 
stomach.     Posterior  gastroenterostomy.      Infolding  of  ulcer. 

Report  December,  1908:  "Has  gained  1  stone  2  lbs. 
Has  a  good  appetite;  feels  a  different  man  altogether.  When 
he  eats  certain  food,  e.  g.,  badly  cooked  meat,  it  seems  to 
stop  in  the  gullet,  and  has  to  be  brought  back.  Has  tried 
oysters,  and  finds  that  these  come  back,  and  for  two  or  three 
days  make  all  swallowing  difficult.  All  food  seems  then  to 
have  to  stop  in  the  gullet."  (When  in  the  Infirmary,  a  skiagram 
shewed  some  dilatation  of  the  oesophagus  and  cardiospasm.) 

Case  169. — D.  June  17,  1908.  G.  E.  F.,  male,  aged 
thirty-eight.  For  thirteen  years  has  suffered  from  attacks 
of  aching,  griping  pain  on  the  right  side  of  the  abdomen. 
There  have  been  intervals  of  relief  of  varying  length.  At 
first  the  pain  was  relieved  by  food,  but  gradually  that  ceased  to 


Detailed  Statement  of  Cases  Operated  Upon  415 

give  relief.  Care  in  diet  has  had  no  effect.  No  vomiting, 
except  on  one  occasion,  four  or  five  years  ago.  Has  never 
had  mehena. 

Operation:  The  whole  surface  of  the  stomach,  especially 
the  pyloric  end  and  first  part  of  duodenum,  shewed  numer- 
ous adhesions  suggesting  perforation.  The  right  lobe  of  the 
liver  was  adherent  to  the  pylorus.  Transverse  mesocolon  was 
intimately  adherent  to  the  mesentery.  These  adhesions  were 
divided;  the  lesser  sac  was  opened,  and  an  attempt  made  to 
bring  the  posterior  wall  of  the  stomach  to  the  surface.  This 
was  found  to  be  impossible,  owing  to  the  adhesions  around 
the  pylorus.  The  opening  in  the  mesocolon  was  therefore 
closed  and  an  anterior  gastro-enterostomy  performed  about 
9  inches  below  duodenojejunal  flexure.  The  proximal  loop 
was  divided  and  the  end  implanted  into  the  distal.  (Modi- 
fied Roux's  operation.)  Recovery.  Sent  by  Dr.  Fisher  Ward, 
Bawtry. 

Report  December,  1908:  Is  fit  and  well;  has  kept  to  work 
continuously  since  he  started  after  the  operation,  and  has 
never  had  to  consult  me.  He  is  a  signal-man  on  the  railway, 
and  has  recently  applied  for,  and  been  appointed  to,  a  more 
important  post.  Before  his  operation  he  had  to  give  up 
several  better  posts  and  take  a  gradually  reduced  wage. 

Case  170. — D.  July  27,  1908.  A.  W.  J.,  male,  aged 
fifty-seven.  For  twenty  years  has  had  pain  coming  on  after 
food  and  relieved  by  vomiting.  Always  worse  in  winter. 
An  attack  of  haematemesis  twelve  years  ago,  with  tarry  stools 
and  fainting.  Last  summer  he  became  worse  than  ever, 
with  much  pain  during  the  night.  The  pain  is  dull,  heavy, 
and  aching,  situated  in  the  epigastrium,  and  accompanied 
by  much  flatulence.  It  occurs  two  to  three  hours  alter  food 
and  is  relieved  b\  ,i  meal.  For  the  lasl  tWO  years  has  been 
unable    to   work. 

Operation:  A  large  ulcer  just  beyond  the  pylorus  with 
considerable  induration.  Posterior  gastro-enterostomy.  In- 
folding of  ulcer.    Recovery.    Sen1  bj   Dr.  Waugh,  Skipton. 

Report    December,    [908:      Has  gained   7   lbs.      Is  feeling 

well,   and    says   he   is   belter    than    he    has   been    lor   years   and 

can  eat  practically  anything. 


416  Duodenal  Ulcer 

Case  171. —  I).  August  7,  1908.  A.  W.  P.,  male,  aged 
twenty-two.  Complains  of  severe  pain,  coming  on  about 
two  hours  after  food,  commencing  over  the  cardiac  area  of 
the  stomach,  radiating  over  the  whole  of  the  abdomen,  and 
spreading  round  to  the  back.  For  five  years  this  pain  has 
occurred  in  attacks  which  have  gradually  become  more 
frequent  and  severe.    The  pain  is  usually  relieved  by  vomiting. 

Operation:  A  large,  well-marked  ulcer  on  the  anterior  wall 
of  the  duodenum  immediately  beyond  pylorus.  Posterior 
gastroenterostomy.  Infolding  of  ulcer.  Recovery.  Sent 
by  Dr.  Wright,  Boston. 

Report  June,  1909:  "Am  keeping  well.  I  am  able  to 
eat  anything  without  feeling  discomfort  except  for  a  little 
flatulence.  I  can  indulge  in  most  exercises  without  feeling 
any  ill  effects.  There  is  no  sign  of  recurrence  of  my  former 
trouble." 

Case  172. — D.  August  7,  1908.  A.  W.,  male,  aged 
thirty-seven.  In  June,  1905,  posterior  gastroenterostomy 
was  performed  for  duodenal  ulcer.  (See  Case  54.)  This 
relieved  symptoms  for  eighteen  months,  with  the  exception 
of  occasional  vomiting.  Since  then  pain  has  gradually  returned 
and  vomiting  has  become  more  frequent.  Pain  comes  two 
or  three  hours  after  food,  and  is  relieved  by  food,  medicine, 
or  by  lying  down.  He  frequently  vomits  in  the  morning 
about  fifteen  minutes  after  breakfast. 

Operation:  Some  adhesions  between  the  omentum  and  the 
anterior  abdominal  wall.  The  anastomosis  shewed  a  slightly 
longer  "loop"  than  would  be  left  at  the  present  time,  and 
there  was  slight  kinking  proximal  to  the  anastomosis.  The 
kink  was  straightened  and  one  or  two  adhesions  separated. 
Three  fingers  could  be  easily  passed  through  the  anastomosis. 
The  pylorus  was  found  to  be  patent,  and  at  the  site  of  the 
ulcer  found  at  first  operation,  of  which  a  drawing  had  been 
made,  a  large  scar  was  found.  Close  to  this  were  two  well- 
marked  ulcers,  evidently  of  recent  date.  The  pylorus  was 
closed  by  sutures  which  infolded  the  ulcerated  area.  In 
this  case  pylorospasm  was  probably  present  with  the  duo- 
denal ulcer.  The  gastroenterostomy  acted  at  first,  then 
ceased  to  do  so.  owing  to  the  pylorus  becoming  patent,  and 


Detailed  Statement  of  Cases  Operated  Upon  417 

this  was  followed  by  recurrence  of  ulceration.  Recovery. 
Sent  by  Dr.  Alderton,  Barnoldswick. 

Report  December,  1908:  Appears  to  be  quite  well;  is 
gaining  in  weight;  no  recurrence  of  symptoms. 

Case  173. — D.  September  1,  1908.  Mrs.  A.,  aged  forty- 
seven.  In  July,  1907,  was  admitted  to  Nursing  Home  with 
the  following  history:  Has  suffered  from  indigestion  for  ten 
or  eleven  years.  Nine  years  ago  a  severe  attack  of  pain 
with  haemorrhage;  has  had  trouble  more  or  less  ever  since, 
especially  during  the  last  two  years.  Now  has  pain  after  food, 
varying  in  time  of  onset;  sometimes  almost  immediately,  but 
generally  about  two  hours  afterwards.  Usually  lasts  until 
another  meal  is  taken.  It  rarely  occurs  at  night.  No  hsemat- 
emesis  recently.  Solid  food  appears  to  cause  her  less  dis- 
comfort than  liquids,  and  she  says  that  the  latter,  particularly 
water,  almost  invariably  cause  immediate  pain.  She  has  lost 
over  a  stone  in  weight.  A  diagnosis  of  duodenal  ulcer  was 
made. 

Operation:  July  18,  1907.  There  was  no  evidence  of  a 
lesion  in  the  duodenum  on  palpation  or  inspection;  on  the 
lesser  curvature  of  the  stomach,  at  a  point  slightly  to  the 
cardiac  side  of  its  centre,  was  a  large  ulcer  with  considerable 
surrounding  induration,  extending  on  to  both  the  anterior 
and  posterior  walls.  The  ulcer  was  excised  and  the  incision 
sutured.  No  gastroenterostomy  was  performed.  For  four 
months  relief  followed  the  operation,  and  then  pain  began  to 
recur.  It  came  two  to  three  hours  after  food  and  was  always 
relieved  by  the  next  meal.  There  was  no  vomiting.  Weight, 
which  had  been  gained,  was  rapidly  lost. 

Operation:  September,  1908.  The  scar  of  the  former 
excision  was  found  to  be  perfect.  There  were  a  few  thin 
adhesions,  but  no  narrowing  of  tin-  lumen.  The  first  part  of 
1  he  duodenum  was  surrounded  by  adhesions  and  a  large  indu- 
rated ulcer  was  present  on  its  anterior  surface.  Posterior 
gastro-enterostomy  was  performed,  the  ulcer  infolded,  and  the 

pylorus  closed.  Recovery.  Sent  by  Dr.  Tweedy,  Northaller- 
ton. 

Report   December,   [908:     "Mrs.  A.  has  done  well.     Can 

27 


418  Duodenal  Ulcer 

cat  anything  without  pain  or  sickness,  and  has  regained  her 
normal  weight  and  strength.'' 

Case  174. — I).  September  4,  1908.  A.  N.,  female,  aged 
thirty-five.  Has  had  indigestion  for  the  last  twenty  years. 
Ten  years  ago  an  attack  of  haematemesis;  since  than  has  had 
a  recurrence  of  haemorrhage  on  four  or  five  occasions.  The 
last  occasion  was  in  June,  when  there  was  considerable  melaena. 
Suffers  from  pain  twro  to  three  hours  after  food,  with  much 
flatulence  and  vomiting  of  large  quantities  of  frothy  and 
yeasty  material.     A  large,  waving  stomach. 

Operation:  A  large,  puckered  ulcer  was  seen  on  the  ante- 
rior wall  of  the  duodenum  immediately  beyond  the  pylorus, 
producing  considerable  stenosis.  Stomach  was  dilated. 
Posterior  gastroenterostomy.  Infolding  of  ulcer.  Recovery. 
Sent  by  Dr.  Normington,  Nelson. 

Report  December,  1908:  "Can  digest  any  ordinary  plain 
food.  Has  gained  in  weight,  but  is  still  rather  anaemic.  No 
recurrence  of  pain  nor  vomiting." 

Case  175.- — D.  September  26,  1908.  J.  L.  W.  (medical 
man),  aged  fifty.  Has  had  stomach  trouble  for  twenty  years. 
Periodic  attacks  of  burning  pain  coming  two  to  three  hours 
after  food,  relieved  by  the  vomiting  of  a  small  quantity  of 
intensely  acid  mucus.  Always  relieved  by  food  or  lavage. 
Twelve  years  ago  a  slight  attack  of  haematemesis.  In  1901 
an  attack  of  acute  appendicitis  with  subsequent  appendicec- 
tomy.  The  present  attack  of  pain  began  in  March.  He 
washes  the  stomach  out  usually  twice  in  the  twenty-four 
hours;  often  has  to  do  so  in  the  early  morning  (2  A.  M.). 

Operation:  A  scarred  ulcer  with  central  depression  the 
size  of  a  sixpence  on  the  anterior  surface  of  the  first  part  of 
the  duodenum.  Stomach  and  gall-bladder  normal.  Pos- 
terior gastroenterostomy.     Infolding  of  ulcer.     Recovery. 

Report  from  patient  March  24,  1909:  "Very  well,  but  am 
still  rather  easily  tired.  I  have  gained  weight.  The  result 
of  the  operation  has  been  to  make  a  new  man  of  me.  I  have 
lost  the  'duodenal  ulcer  aspect.'  Am  able  to  eat  anything 
that  is  put  before  me,  but  never  make  a  large  meal.  My 
stomach  is  quite  comfortable,  better  than  it  has  been  for 
twenty  years,  and  I  should  not  know  that  anatomically  all 
was  not  quite  natural." 


Detailed  Statement  of  Cases  Operated  Upon  419 

Case  176. — G.  &  D.  September  28,  1908.  A.  F.  (medical 
man),  aged  forty.  For  the  last  seven  years  has  suffered  from 
frequent  attacks  of  pain  of  a  burning,  gnawing  character 
two  hours  after  food;  much  worse  during  the  last  two  years. 
During  the  last  year  has  had  one  or  two  very  severe  attacks 
of  pain  suggesting  perforation.  Food  and  carbonate  of  soda 
have  relieved  the  pain;  during  the  last  few  months  pain  has 
occurred  earlier,  coming  on  very  soon  after  food,  and  lasting 
for  about  an  hour.  There  has  been  no  vomiting,  and  no 
melaena  so  far  as  he  is  aware. 

Operation:  Stomach  large  and  hypertrophied.  First  part 
of  duodenum  much  scarred  and  slightly  contracted.  On  the 
posterior  surface  of  the  stomach,  just  to  the  proximal  side 
of  the  pylorus,  a  crateriform  ulcer  the  size  of  a  shilling.  Some 
adhesions  in  the  lesser  sac.  Posterior  gastroenterostomy. 
Infolding  of  duodenum.  The  appendix  was  found  to  be 
chronically  inflamed  and  distended  with  faecal  material  in  its 
distal  half.  Appendicectomy.  Recovery.  Sent  by  Dr.  John 
Campbell,  Belfast. 

Report  March,  1909:  Weight  remains  the  same;  recently 
there  has  been  some  improvement,  but  since  the  operation 
there  has  been  some  pain  after  every  meal.  This  pain  is 
situated  in  the  right  side  of  the  abdomen  and  in  the  back 
and  chest,  and  is  similar  to  that  felt  before  the  operation. 

This  patient  was  seen  in  August  and  is  much  better. 

Case  177. — D.  September  29,  1908.  Mr.  D.,  aged  forty- 
five.  For  twenty  years  has  had  periodical  attacks  of  pain 
three  to  four  hours  after  food,  relieved  by  food.  These  were 
always  worse  in  cold  weather.  Seldom  vomited  and  has 
never  been  jaundiced.  I  hiring  the  last  two  years  attacks 
have  been  longer  and  more  severe.  The  presenl  attack  began 
during  the  fir>t  week  in  September  and  is  much  the  worst 
he  has  ever  had.  He  has  been  confined  to  bed  and  has  suf- 
fered Irom  almost  constant  acute  pain  in  the  epigastrium,  with 
much  flatulence  and  frequent  vomiting  of  considerable  quan- 
tities of  bile-stained  fluid.  On  examination,  the  abdomen  is 
slightly  distended  and  thereis  greal  tenderness  and  rigidity 
in  the  ri^ht  epigastric    and  hypochondriac  regions. 

Operation:    A  large,  indurated  nicer  on  the  anterior  surface 


420  Duodenal  Ulcer 

of  the  first  part  of  the  duodenum,  with  many  surrounding 
adhesions  and  much  recent  lymph.  Evidently  a  subacute 
perforation  of  the  ulcer.  Stomach  was  much  dilated.  Pos- 
terior gastroenterostomy.  Infolding  of  ulcer.  During  con- 
valescence a  severe  attack  of  bronchitis.  Sent  by  Dr.  Veale, 
Drighlington. 

This  patient  was  seen  January,  1909.  He  was  rapidly 
gaining  weight,  doing  his  ordinary  work,  and  suffered  no 
discomfort  whatever.  Report  May,  1909:  Absolutely  well; 
better  than  he  has  been  for  twenty  years.  Has  gained  2 
stone  5  lbs. 

Case  178. — D.  September  30,  1908.  B.,  male,  aged 
sixty-one.  Six  years  ago  a  choledochotomy  performed  for 
stone  in  the  common  duct.  Was  fairly  well  until  September, 
1907.  Then  had  an  acute  and  sudden  attack  of  epigastric 
pain,  which  caused  him  to  roll  on  the  floor  in  agony.  Was 
very  ill  for  a  few  days;  slowly  recovered,  but  was  never  quite 
well.  In  March,  1908,  a  similar  but  less  severe  attack,  ac- 
companied by  the  vomiting  of  a  considerable  amount  of 
blood  on  two  occasions.  Since  then  scarcely  ever  free  from 
pain,  which  is  aching  in  character  and  passes  through  from 
the  epigastrium  to  between  the  shoulders.  Vomits  about 
four  times  a  week  large  quantities  of  frothy  fluid.  Has  lost 
2^  stone  in  weight.  On  examination,  stomach  is  dilated, 
with  visible  peristalsis.  A  hard,  tender  tumour  is  situated 
in  the  right  hypochondrium,  involving  the  abdominal  wall  in 
the  situation  of  the  old  incision. 

Operation:  The  anterior  surfaces  of  the  stomach  and  duo- 
denum were  buried  in  a  mass  of  adhesions  which  bound  them 
to  the  anterior  abdominal  wall.  A  hard  mass  was  palpable 
in  the  first  part  of  the  duodenum — evidently  an  ulcer  which 
had  previously  perforated.  Posterior  gastro-enterostomy  per- 
formed with  considerable  difficulty.  Recovery.  Sent  by  Dr. 
Carnes,  Leeds. 

Report  March,  1909:  States  that  he  is  in  better  health 
now  than  he  has  been  for  four  or  five  years.  Has  gained  about 
I x/2  stone  in  weight.  No  recurrence  of  pain  or  vomiting; 
takes  ordinary  food.  Does  not  diet  himself  and  suffers  no 
discomfort  after  meals. 


Detailed  Statement  of  Cases  Operated  Upon  42 1 

Case  179. — D.  October  5,  1908.  F.  S.,  male,  aged  twenty- 
three.  During  the  last  twelve  months  has  suffered  from  pain 
occurring  one  and  one-half  to  two  hours  after  food.  At  first 
this  was  relieved  by  medicinal  treatment,  but  during  the  last 
seven  months  he  has  had  pain  almost  constantly,  and  on 
one  occasion  has  had  hsematemesis.  Much  flatulence  and 
feeling  of  fullness  in  the  epigastrium. 

Operation:  A  large,  well-marked  ulcer  on  the  anterior 
surface  of  the  duodenum  just  beyond  pylorus.  Posterior 
gastroenterostomy.  Ulcer  infolded.  Recovery.  Sent  by  Dr. 
Carse,  Rochdale.- 

Report  March,  1909:  "He  is  certainly  improved  in 
appearance;  is  losing  his  anaemia  and  slowly  regaining  his 
strength.  His  appetite  is  poor,  and  he  is  still  troubled  with 
acid  eructations  occurring  about  one  hour  after  food.  He 
will  not  admit  that  he  is  improved,  but 'I  think  that  he  is." 

Report  September,  1909:  "He  has  gone  to  work  last  week 
for  first  time  since  operation.  Much  improved  in  strength 
and  increasing  in  weight;  he  does  not  now  shew  any  signs  of 
ana?mia.  Still  troubled  with  acid  eructations  one-half  to  one 
hour  after  food  (his  teeth  are  very  defective).  No  pain  and 
no  vomiting.    Rather  troubled  by  flatulence  and  borborygmi." 

Case  180. — D.  October  13,  1908.  Mr.  D.,  aged  fifty. 
Was  admitted  complaining  of  jaundice  of  great  intensity. 
Says  that  he  was  quite  well  until  nearly  the  end  of  July  last ; 
then  began  to  suffer  from  distressing  flatulence  and  distension 
alter  food.  The  pain  was  never  acute  nor  colicky,  nor  did 
he  vomit.  There  wire  occasional  periods  of  relief  for  a  tew 
days.  Six  weeks  ago  the  discomfort  became  more  intense 
and  he  began  to  be  jaundiced.  Since  that  time  pain  has  been 
absent,  bm  the  jaundice  has  gradually  deepened.  He  does 
not  think  that  it  has  become  le>s  in  intensity  at  any  time. 
There  have  been  no  pyrexia  and  no  shivering.  He  has  losl  2 
-lone  in  weight.  (  )n  examination,  patient  is  intensely 
jaundiced;  ol  a  greenish-brown  tint.  Stool:-  are  grey,  copious, 
.nid  formed.  Urine  is  bile-stained.  The  liver  is  palpable;  its 
bonier  i-  smooth  and  regular.     The  gall-bladder  can  be  indis- 

1  iii<  1  Iv   defined,    but    is    not    tender. 

Report  on  examination  of  mine  and  faeces:    The  presence 


422  Duodenal  Ulcer 

of  a  well-marked  pancreatic  reaction  (Cammidge)  in  the  urine 
points  to  some  degree  of  chronic  pancreatitis,  and  the  result 
of  the  examination  of  the  faeces  confirms  this.  There  is  a 
high  percentage  of  total  fats,  of  which  nearly  half  are  combined 
fatty  acids,  indicating  that  although  the  pancreas  is  affected, 
occlusion  of  the  pancreatic  duct  is  not  complete  and  the 
obstruction  of  the  common  bile-duct  must  be  above  its  junc- 
tion with  the  pancreatic;  that  the  obstruction  of  the  common 
duct  is  almost  complete  is  shewn  by  the  presence  of  only  a 
trace  of  stercobilin  in  the  faeces,  but  the  absence  of  undigested 
matter  in  the  microscopic  examination  of  the  faeces  also  sup- 
ports the  conclusion  that  the  primary  site  of  the  disease  is 
in  the  common  bile-duct  and  not  in  the  pancreas.  The  per- 
centage of  ash  shews  that  there  is  no  colitis,  and  the  absence 
of  blood  is  in  favour  of  there  being  no  lesion  in  the  alimentary 
tract. 

Operation:  The  liver  was  much  enlarged  and  the  gall- 
bladder dilated,  with  thick,  white  walls.  The  cystic  and 
common  ducts  were  dilated  as  far  as  the  upper  margin  of  the 
duodenum,  where  there  was  an  indurated  scar  which  appeared 
to  be  involving  and  compressing  the  common  duct.  There 
was  no  tumour  of  the  head  of  the  pancreas  nor  were  any 
calculi  palpable  in  the  biliary  passages.  The  gall-bladder 
was  aspirated  and  found  to  contain  clear  mucus  only.  The 
duodenal  ulcer  was  deemed  to  be  the  cause  of  the  obstruc- 
tion, and  an  anastomosis  was  performed  between  the  gall- 
bladder and  the  transverse  colon,  as  it  was  found  impossible 
to  unite  the  duodenum  to  the  gall-bladder  without  dangerous 
tension.  Recovery.  On  November  ist  the  urine  was  much 
less  bile-stained  and  the  faeces  were  approaching  the  normal 
in  colour.  Jaundice  rapidly  diminishing.  Patient  sent  by 
Dr.   Dunderdale  of  Blackpool. 

Report  March,  1909:  Somewhat  sallow;  free  from  pain; 
bowels  regular;  appetite  good;  gaining  weight  'slowly  and 
regularly  ("he  has  gained  2  stone  since  the  operation"). 
Between  December  28,  1908,  and  January  5,  1909,  had  three 
attacks  of  colicky  pain  over  gall-bladder  region,  followed  by 
elevation  of  temperature  and  jaundice  lasting  three  or  four 
days.     He  now  appears  to  be  quite  free  from  all  his  former 


Detailed  Statement  of  Cases  Operated  Upon  423 

inconvenience.  Report  September,  191 1:  Dr.  Dunderdale 
writes:  "I  am  pleased  to  report  that  your  patient  Mr.  D., 
is  in  good  health  and  performs  his  allotted  task  in  quite  an 
ordinary  manner.  On  the  31st  ult.  his  weight,  without  coat, 
was  15  stone  7  lbs.,  and  beyond  occasional  constipation 
for  two  or  three  days  in  each  fortnight  he  has  nothing  to 
complain  of.  The  result  in  his  case  must  be  considered  most 
satisfactory." 

Case  181. — D.  October  19,  1908:  Mr.  C,  aged  forty. 
For  eighteen  or  nineteen  years  periodic  attacks  of  pain,  of 
an  aching,  boring  character,  in  umbilical  and  lower  dorsal 
region,  coming  on  about  three  hours  after  food,  and  lasting 
until  next  meal.  Occasional  vomiting  of  small  quantities  of 
acid  mucus.  April,  1903,  a  severe  attack,  of  haematemesis 
and  melaena.  February,  1905,  another  attack;  in  February, 
1907,  and  June,  1908,  similar  attacks.  Since  April,  1903,  the 
characteristic  attacks  of  pain  have  been  almost  entirely  absent. 

Operation:  The  anterior  surface  of  the  first  part  of  the 
duodenum  was  found  to  be  a  mass  of  scar  tissue,  evidently 
due  to  multiple  ulcers.  Posterior  gastroenterostomy.  In- 
folding of  ulcerated  area.  Recovery.  Sent  by  Dr.  Aitcheson, 
Blackburn. 

Report  February,  1909:  Is  very  well;  the  only  discomfort 
he  has  had  has  been  a  little  constipation  after  the  operation. 
The  bowels  are  now  regular  and  he  has  no  discomfort  of  any 
sort.     I>  gaining  weight. 

Case  182. — G.  &  D.  October  23,  1908.  Mr.  (".,  aged 
twenty-six.  For  four  or  five  years  has  suffered  from  fullness 
.mil  distension  in  epigastric  region,  with  regurgitation  of 
acid  fluid  into  the  throat  occurring  about  two  hours  after 
food.  Xo  vomiting  until  eighteen  months  ago,  when  he  had 
.hi  attack  <>f  li.cmatemesis  and  mela-na  lasting  two  or  three 
days.  After  the  necessary  confinement  to  bed  and  fluid 
diet  he  was  free  from  pain  for  some  months,  but  symptoms 
began  to  return  and  pain  was  often  severe  al  night.  In 
June,  i<)o*.  melaena,  but  no  haematemesis.  On  getting  up 
from  bed  distension  and  acidity  returned,  and  he  reverted  to 
.i  diet  oi  peptonised  milk,  which  he  h,as  continued  to  the 
presenl  time. 


424  Duodenal  Ulcer 

Operation:  No  gastric  dilatation;  a  large,  indurated  ulcer 
on  anterior  surface  of  first  part  of  the  duodenum,  and  the 
scar  of  a  gastric  ulcer  just  to  the  proximal  side  of  the  pylorus. 
The  two  were  almost  continuous,  and  the  pyloric  vein  was 
obscured  by  the  scarring.  The  first  part  of  the  duodenum 
shewed  marked  pouching.  Posterior  gastroenterostomy  per- 
formed. The  central  portion  of  the  duodenal  ulcer  was 
excised,  the  defect  closed  by  interrupted  catgut  sutures,  and 
the  whole  ulcer-bearing  area  infolded.  Recovery.  Sent  by 
Dr.  Grant,  Colne. 

Report  March,  1909:  Has  gained  more  than  I  stone  in 
weight.     No  recurrence  of  pain  nor  vomiting. 

Case  183. — D.  November  2,  1908.  Colonel  H.,  aged 
forty-three  (medical  man).  For  six  years  has  been  liable  to 
recurring  attacks  of  epigastric  pain,  often  of  a  cramp-like 
nature,  coming  on  two  to  four  hours  after  food.  A  number  of 
these  attacks  appeared  to  be  precipitated  by  getting  wet 
whilst  fishing.  On  one  or  two  occasions  has  been  kept  in 
bed  and  fed  per  rectum,  with  only  temporary  relief.  No 
vomiting  at  any  time;  no  melsena. 

Operation:  A  small,  puckered  ulcer  was  present  on  the 
anterior  surface  of  the  duodenum.  This  was  excised  and  the 
incision  closed  by  interrupted  sutures.  No  gastroenteros- 
tomy performed.     Recovery. 

December  4,  1908:  Patient  reported  that  he  was  feeling 
very  well.  Was  eating  without  discomfort  and  gaining  weight. 
Case  184. — D.  November  10,  1908.  Mr.  C,  male,  aged 
forty-six.  Since  the  age  of  seventeen  has  been  liable  to 
attacks  of  epigastric  pain,  occurring  about  three  and  one- 
half  hours  after  food,  relieved  by  the  next  meal.  There  have 
been  intervals  of  complete  relief  of  varying  duration.  During 
the  last  four  years  pain  has  been  more  frequent  and  severe. 
It  often  wakes  him  at  night,  when  a  glass  of  milk  relieves  the 
pain  for  a  time.  Lately  has  had  some  vomiting,  at  first 
small  in  quantity  and  induced  voluntarily,  but  during  the 
last  week  it  has  been  larger  in  quantity  and  coffee-ground  in 
character.  The  motions  have  been  loose  and  dark  coloured. 
Has  occasionally  experienced  slight  difficulty  in  swallowing 
at  the  commencement  of  the  meal,  as  though  there  was  some 


Detailed  Statement  of  Cases  Operated  Upon  425 

obstruction,   but   this   has   got   less   as   the   meal   progressed 
(slight  cardiospasm?). 

Operation:  Stomach  rather  small;  duodenum  tightly 
tethered  back  beneath  liver  and  could  not  be  pulled  forward. 
A  hard,  indurated  ulcer  the  size  of  a  shilling  at  junction  of 
first  and  second  parts  of  the  duodenum,  adherent  near  neck 
of  gall-bladder.  Posterior  gastroenterostomy  performed  with 
much  difficulty  owing  to  the  inability  to  bring  posterior 
surface  of  the  stomach  forwards.  Xo  attempt  was  made  to 
infold  the  ulcer.     Recovery.    Sent  by  Dr.  Salter,  Manchester. 

Report  June,  1909:  "  I  am  delighted  to  say  I  am  in  splen- 
did health,  and  have  been  ever  since  my  operation.  I  can 
eat  almost  anything.  Nothing  seems  to  disagree  with  me. 
I  sometimes  wonder  whether  I  am  the  same  man  or  not." 

Case  185. — D.  December  5,  1908.  Colonel  C,  aged 
fifty-five.  Very  healthy  until  fifteen  years  ago;  then  began 
to  suffer  from  pain  in  epigastrium,  coming  shortly  before  a 
meal,  relieved  by  food  or  by  a  bismuth  mixture.  Attacks 
of  this  character  recurred  with  intervals  of  a  few  months' 
relief  until  1897,  when  he  was  laid  up  with  a  very  severe 
attack  accompanied  by  vomiting.  From  that  time  to  the 
present  attacks  have  occurred  at  shortening  intervals,  and 
almost  always  accompanied  by  vomiting.  In  1898  and  1899 
underwent  treatment  in  bed,  with  rectal  feeding,  which  gave 
only  temporary  benefit.  The  pain  is  now  usually  worse  in 
the  late  afternoon  and  at  night,  and  interferes  considerably 
with  the  discharge  of  his  duties.  No  haemorrhage  noted  at 
any  time. 

Operation:  A  large,  indurated  ulcer  the  size  of  a  walnut 
in  first  part  of  duodenum,  tightly  adherent  far  back  beneath 
liver.     Recovery.     Sent   by  Dr.  Turner,  York. 

Report  March  16,  1909:  Has  not  been  so  well  for  fifteen 
year>.  At  present  is  in  excellent  health;  has  gained  at  leasl 
1  stone  since  his  operation,  and  now  feels  equal  to  all  his 
military  duties. 

Case  186.— Dr.  I.,  aged  thirty-six.     December  11. 
Between  tour  and  five  years'  history  of  attacks  <>l  pain  com- 
ing on  three  to  four  hours  after  food,  always  relieved  by  food. 

Pain  woke  him  regularly  between  two  and  three  in  the  morn- 


426  Duodenal  Ulcer 

ing.  Never  any  vomiting.  On  one  occasion  motions  were 
tarry.     Pain  often  relieved  by  pressure  or  eructation  of  wind. 

Operation:  Scars  of  several  ulcers  in  the  first  part  of  the 
duodenum.  Posterior  gastroenterostomy.  Ulcers  infolded. 
Recovery. 

Report :  Patient  has  been  seen  frequently  up  to  the  present 
time,  and  is  extremely  well  and  has  no  return  of  trouble. 

Case  187. — D.  December  14,  1908.  Mr.  W.,  aged  forty- 
five.  Since  the  age  of  fifteen  has  been  liable  to  attacks  of 
epigastric  pain  at  varying  intervals.  Pain  is  aching  and 
gnawing  in  character  and  comes  on  about  three  to  four  hours 
after  food.  During  the  day  the  pain  is  not  very  troublesome, 
because  he  takes  his  meals  at  short  intervals.  At  night  it  is 
particularly  bad  and  occurs  in  the  early  morning.  Food 
always  relieves  and  he  has  occasionally  obtained  relief  by 
inducing  vomiting.  He  is  a  well-nourished,  healthy  looking 
man.     There  has  been  no  haematemesis  and  no  melaena. 

Operation:  A  hard,  indurated  ulcer  involving  the  anterior 
wall  of  the  duodenum,  3-"2  mc^  beyond  the  pylorus.  There 
were  some  omental  adhesions  and  the  duodenum  was  tightly 
tethered  back  beneath  the  liver.  Posterior  gastro-enterostomy. 
Ulcer  partially  infolded  with  much  difficulty  and  the  pylorus 
narrowed  by  suture.  Recovery.  Sent  by  Dr.  Molloy,  Black- 
pool. 

Report  March  3,  1909:  Is  perfectly  comfortable;  has  had 
no  symptoms  since  his  return  home;  has  gained  14  lbs.  He 
is  now  back  at  business,  looks  years  younger  than  before 
the  operation,  and  is  in  perfect  health. 

Case  188. — D.  December  18,  1908.  Mr.  M.,  aged  thirty- 
five.  For  twelve  years  has  suffered  from  abdominal  pain 
occurring  some  hours  after  food  and  particularly  bad  at 
night.    Stomach  considerably  dilated. 

Operation:  A  large,  indurated  ulcer  in  the  first  part  of  the 
duodenum.  Considerable  gastric  dilatation  with  hypertrophy. 
Posterior  gastro-enterostomy.  Infolding  of  ulcer.  Recovery. 
Sent  by  Dr.  O'Connel,  Leeds. 

Report  June,  1909:  The  patient  is  doing  very  well.  Has 
had  no  trouble  since  he  left  the  Infirmary.  Takes  food  well; 
appears  to  be  gaining  weight;  says  he  has  not  felt  so  fit  for 
many  years. 


Detailed  Statement  of  Cases  Operated  Upon  427 

Case  189. — D.  December  18,  1908.  A.  W.,  fnale,  aged 
twenty-nine.  For  the  last  six  years  has  had  pain,  coming 
on  about  two  hours  after  food,  lasting  until  the  next  meal, 
which  relieves  it.  Frequent  vomiting,  which  also  gives  relief. 
On  a  number  of  occasions  has  had  haematemesis  and  melaena. 

Operation:  An  ulcer  on  the  anterior  surface  of  the  first 
part  of  the  duodenum.  No  gastric  dilatation.  Posterior 
gastroenterostomy.  Infolding  of  ulcer.  Recovery.  Sent  by 
Dr.  Dawson,  Bradford. 

This  patient  cannot  be  traced. 

Case  190. — D.-  December  31,  1909.  Mr.  M.,  aged  forty. 
At  the  age  of  twelve  an  attack  of  acute  abdominal  pain  of  a 
colicky  nature,  necessitating  the  application  of  poultices,  etc. 
For  the  last  two  years  has  suffered  from  periodical  attacks  of 
aching  pain  across  the  upper  part  of  the  abdomen,  with  much 
flatulence,  coming  on  without  warning  and  lasting  for  two 
or  three  weeks  at  a  time.  Not  colicky  in  nature,  but  more 
of  the  character  of  an  aching  discomfort.  The  pain  was  not 
continuous  nor  did  it  trouble  him  at  night,  but  whilst  an 
attack  was  on  he  had  the  pain  at  some  time  or  another  every 
day.  The  intervals  between  the  attacks  varied  in  duration 
and  he  not  infrequently  suffered  from  sharp  twinges  of  pain 
in  the  right  iliac  fossa.  Food  appeared  to  have  no  relation 
to  the  pain  and  he  has  had  no  vomiting  and  no  jaundice. 
Three  months  ago  the  bowels  were  rather  loose  and  mUcus 
was  frequently  present  in  the  stools;  recently  they  have  been 
slightly  constipated.  On  no  occasion  has  he  had  an  attack 
of  pain  which  could  be  described  as  colicky.  Tin-  attacks 
recently  have  been  more  frequent  and  discomfort  has  been 
most  marked  beneath  the  right  costal  margin.  He  has  never 
had  typhoid.  Abdominal  examination  negative.  Sent  by 
Dr.  Bentley,  Stockport. 

Operation:  Battle's  incision.  Appendix  long  and  narrow 
and  showing  evidence  of  inflammation;  it  was  lying  to  outer 
side  of  the  caecum  with  its  tip  pointing  upward--.  Appendicec- 
tomy.     Gall-bladder   palpated    and    inspected;   although    no 

Calculi   COuld    Ik-   felt,   its  walls  looked   suspiciously   white,   so  a 

second  incision  was  made  over  it.    The  gall-bladder  was  found 
to  contain   no  calculi,  lint    the  duodenum   was  tightly   tucked 


428  Duodenal  Ulcer 

beneath  the  liver  and  a  sharp-edged,  band-like  adhesion  passed 
across  its  anterior  surface  and  up  towards  the  under  surface 
of  the  liver.  A  hard,  indurated  scar  just  beyond  pylorus, 
evidently  a  duodenal  ulcer.  Posterior  gastroenterostomy. 
Infolding   of    ulcer. 

Report  June,  1909:  "Have  gained  about  2  stone  since 
the  operation.  No  recurrence  of  pain.  Am  again  on  regular 
diet  and  have  a  very  good  appetite.  Occasionally  slightly 
troubled  with  flatulence,  but  am  very  much  healthier  in  every 
way." 


APPENDIX     II 

ADDITIONAL  CASES  OPERATED  UPON  IN  1909  AND  19 10 


The  additional  case  histories,  included  in  the  second 
edition  are  those  of  patients  operated  upon  during  the 
years  1909  and  1910 — -115  in  number. 

Sex. — Males,  93,  or  80.9  per  cent.;  females,  22,  or 
19. 1  per  cent. 

Age. — The  distribution  of  the  patients  in  the  various 
decennial  periods  is  as  follows: 

One  to  twenty None 

Twenty-one  to  thirty 19 

Thirty-one  to  forty 25 

Forty-one  to  fifty 33 

Fifty-one  to  sixty l4 

Sixty-one  to  seventy 4 

Age  not  stated ■' 20 

Variety  of  Ulcer. — Duodenal  ulcer  was  found  alone  in 
101  cases  (87.8  per  cent.);  of  these,  86  were  males  and 
15  females,   a  proportion  of  almost  six  to  one.     Both 


Detailed  Statement  of  Cases  Operated  Upon  429 

gastric  and  duodenal  ulcers  were  present  in  11  cases 
(9.56  per  cent.) :  five  of  them  were  males  and  six  females. 

In  two  cases,  one  male  and  one  female,  carcinoma  of 
the  stomach  was  present  along  with  duodenal  ulcers. 

In  one  case  (No.  273)  the  patient  was  suffering  from 
tabes,  and  it  is  doubtful  whether  a  duodenal  ulcer  was 
present ;  the  details  of  the  case  are  fully  described  in  the 
text. 

Haemorrhage. — In  the  101  cases  in  which  duodenal 
ulcer  alone  was  found  haemorrhage  had  occurred  in  49; 
of  these,  9  had  apparently  suffered  from  haematemesis 
alone,  10  from  melaena  only,  and  in  21  both  haematemesis 
and  melaena  had  been  observed. 

Amongst  the  11  cases  in  which  both  gastric  and  duo- 
denal ulceration  was  present  4  had  suffered  from  haem- 
atemesis  and    1   from   both   haematemesis  and  melaena. 

Stenosis. — In  13  of  the  101  cases  of  duodenal  ulcer 
stenosis  of  the  duodenum  was  present  and  had  produced 
gastric  dilatation,  and  in  4  of  these  the  dilatation  was 
very  great. 

Perforation  of  Ulcers. — In  4  cases  (245,  251,  262, 
290 )  there  was  evidence  that  a  subacute  perforation  had 
previously  occurred. 

Operative  Treatment. — Upon  the  115  patients  116 
operations  have  been  performed.  Case  298  was  operated 
upon  a  second  time  in  191 1. 

The  operations  may  be  classified  as  follows: 

Posterior  vertical  gastroenterostomy  with  infolding  of  ulcei 
— generallj  with  appendicectomy i<>" 

Posterior  vertical  gastro  enterostomy  \sith  infolding  of  ulcer 
— generally  with  appendicectomy  (Mayo's  method)  (case 

1 


43°      •  Duodenal  Ulcer 

Posterior  vertical  gastroenterostomy  with  infolding  of  ulcer 

— generally  with  cholecystectomy  (case  301) 1 

Posterior  vertical  gastroenterostomy  with  infolding  of  ulcer 
— generally  with  cholecystectomy  and  appendicectomy 

(case  228) 1 

Excision  of  jejunal  ulcer  (case  298) 1 

Excision  of  jejunal  ulcer  with  gastrogastrostomy  (case  227) .  .        1 
Excision  of  jejunal  ulcer  with  excision  of  gastric  ulcer  (case 

270) 1 

Excision  of  jejunal  ulcer  with  partial  gastrectomy  (cases  285, 

292) 2 

Excision  of  jejunal  ulcer  with  radical  cure  of  epigastric  hernia 

(case  193) I 

Excision  of  jejunal  ulcer  with  excision  of  duodenal  ulcer  (case  • 

225) 1 

Excision  of  duodenal  ufcer  (cases  192,  215) 2 

Excision  of  duodenal  ulcer  with  cholecystotomy  and  appendi- 
cectomy (case  280) 1 

Gastroenterostomy  and  appendicectomy  (case  293) 1 

Modified  Roux's  operation  (case  264) 1 

Posterior  gastro-enterostomy,  cholecystotomy,  and  appendi- 
cectomy (case  297) 1 

Total 116 

Operative  Results. — In  one  instance,  case  305,  the 
last  of  the  series,  a  fatal  result  occurred.  The  patient, 
who  was  extremely  ill  and  anaemic  .before  operation,  died 
of  sudden  cardiac  failure  on  the  thirteenth  day. 

At  autopsy  no  lesion  other  than  fibroid  degeneration 
of  the  myocardium  could  be  found  to  account  for  death. 

Between  this  case  and  the  last  fatal  case  of  the  pre- 
vious series  (case  112)  192  consecutive  operations  had 
been  performed  without  a  death.  Two  patients  have 
since  died  from  other  causes. 

Case  233. — Committed  suicide  ten  months  after 
operation  as  the  result  of  business  and  family  troubles. 
So  far  as  the  results  of  the  operation  are  concerned  it  had 
apparently  been  a  complete  success. 

Case  272. — Died  two  months  later  of  carcinoma  of  the 


Detailed  Statement  of  Cases  Operated  Upon  43 1 

liver,  which  was  noted  at  the  operation,  but  the  primary 
seat  of  which  was  not  found. 

Two  patients  must  be  classified  as  unrelieved  by  the 
operation : 

Case  273. — This  man  was  undoubtedly  suffering  from 
tabes  at  the  time  of  'operation,  but  his  symptoms  also 
suggested  the  presence  of  a  duodenal  ulcer.  At  opera- 
tion the  pancreas  was  found  to  be  tightly  embracing  the 
second  part  of  the  duodenum,  and  some  induration  was 
present,  but  it  is  doubtful  whether  there  was  any  actual 
ulceration.  The  operation  appears  to  have  been  of  no 
benefit.     The  case  is  quoted  in  detail  in  the  text. 

Case  298. — In  this  case  an  indurated  ulcer  was  found 
in  the  first  part  of  the  duodenum,  and  for  a  month  or  two 
marked  benefit  resulted  from  gastro-enterostomy,  but 
the  patient  returned  in  May,  191 1,  with  a  recurrence  of 
symptoms;  these  were  found  to  be  due  to  a  jejunal  ulcer 
at  the  site  of  the  anastomosis;  the  ulcerated  area  was 
excised.  Sufficient  time  has  not  elapsed  since  the 
second  operation  to  enable  one  to  say  whether  the  cure  is 
likely  to  be  permanent. 

In  three  cases  the  patients  are  much  relieved  but  not 
quite  well. 

Case  222. — This  man  is  much  better  in  general  health, 
has  no  pain,  but  suffers  from  vomiting  of  small  quantities 
of  bile*stained  mucus  and  foods  about  an  hour  after 
food.  In  the  anamnesis  it  is  stated  that  he  had  been 
troubled  with  regurgitation  of  food  since  boyhood;  the 
typical  symptoms  of  duodenal  ulcer  were  of  much 
shorter  duration. 

Case  282. — This  patient  shews  very  great  improve- 


432  Duodenal  Ulcer 

ment,  but  still  complains  of  a  little  pain  before  meals  and 
occasional  sour  eructations. 

Case  288. — Still  has  attacks  of  pain  followed  by  vomit- 
ing, but  these  are  much  less  frequent  and  severe  than 
before  operation. 

The  cases  in  which  a  duodenal  ulcer  was  excised  with- 
out the  performance  of  a  gastro-enterostomy  are  entirely 
relieved. 

In  5  cases  (212,  227,  261,  276,  287)  no  report  can  be 
obtained.  In  1  or  2  cases  the  reports  state  that  the 
patients  have  vomited  occasionally  since  operation,  but 
there  is  no  case  of  true  regurgitant  vomiting. 

In  102  cases  the  report  is  entirely  satisfactory  and  the 
patients  may  be  classed  as  cured. 

Summarising  the  reports  in  the  last  series  we  have  the 
following  result: 

Total  cases 115 

Died  as  result  of  operation 1  =  0.87% 

Died  later  of  other  causes 2  =  1.7  % 

Cured , 102  =  88.7  % 

Improved 3  =  2-6  % 

Xo  better 2  =  1.7  % 

Not  traced 5  =  4-3  % 

Combining  the  results  of  the  two  series,  there  are  302 
cases,  which  give  the  following  result: 

Total  cases 3°2 

Died  as  result  of  operation 5  =  1.65% 

Died  at  varying  periods  of  other  causes 6=  2      % 

Cured 250  =  82.78% 

I  mproved 21=  7      % 

Doubtful  improvement I  —  -32% 

Xo  b-tter „.  .  .  3  =  -96% 

Xot  traced 16  =  5.3  % 

Case  191. — D.     January   15,    1909.     W.   M.,   male,  aged 


Detailed  Statement  of  Cases  Operated  Upon  433 

forty-four.     Fourteen  years'  history  of  attacks  of  pain  three 
hours  after  food.     No  melaena,  very  little  vomiting. 

Operation:  Large  ulcer  on  posterior  surface  of  duodenum. 
Posterior  gastroenterostomy.    Infolding  of  ulcer.     Recovery. 

Report  October,  19 10:  In  perfect  health,  gained  over  2 
stone. 

Case  192. — D.  January  29,  1909.  A.  H.,  female,  aged 
twenty-seven.  Two  years'  history.  On  one  occasion  ha?mat- 
emesis  and   also   melaena. 

Operation:  An  ulcer  on  anterior  aspect  of  duodenum,  half- 
inch  from  the  pylorus,  with  an  omental  adhesion.  Adhesion 
divided;   ulcer  excised.     Sent  by  Dr.  Williamson,  Otley. 

Report  August,  191 1 :  Is  quite  well  and  takes  no  medicine 
nowadays,  so  this  seems  quite  satisfactory. 

Case  193. — D.  February  2,  1909.  W.  M.,  male,  aged 
twenty-six.  Eighteen  months  ago  noticed  a  swelling  in  epi- 
gastric region,  accompanied  by  severe  pain  and  vomiting 
lasting  for  some  days,  when  lump  disappeared  and  symptoms 
subsided.  Similar  attacks  have  recurred.  On  examination  a 
small  epigastric  hernia  is  palpable. 

Operation:  Stomach  found  to  be  distinctly  hypertrophied, 
but  not  dilated.  Several  old  scars  just  beyond  pylorus.  A 
large  ulcer  beyond  these,  causing  some  mechanical  obstruc- 
tion. Radical  cure  of  hernia.  Posterior  gastroenterostomy. 
Infolding  of  pylorus.     Recovery.    Sent  by  Dr.  E.  R.  Flint. 

Report  October,  1910:  Says  he  was  never  better  in  his 
life.     Is  working  out-of-doors,  and  feels  very  well. 

Case  194. — D.  February  25,  1909.  Dr.  A.,  twenty  to 
thirty  years'  history  of  periodic  attacks  of  pain  two  to  three 
hours  after  food.    Severe  haemorrhages  in  1896,  1907,  and  1908. 

Operation:  An  ulcer  the  size  of  a  shilling  on  anterior  and 
upper  surface  of  first  part  of  duodenum,  adhesions  t<>  neck 
of  gall-bladder.  Posterior  gastroenterostomy.  Infolding  of 
ulcer.     Recovery. 

Report  October,  1909:  No  recurrence  of  pain  nor  haemor- 
rhage, no  vomiting,  no  stomach  symptoms. 

Case   [95.     1).     March  1,  i<jo<).     Mr.  A.,  aged  forty-one. 
Periodic  attacks  of  pain   two  to  three  hours  alter  food   for 
five  years,     No  haematemesis  nor  melaena. 
28 


434  Duodenal  Ulcer 

Operation:  Indurated  ulcer  just  beyond  pylorus,  adhesions 
to  gastro-hepatic  omentum.  Posterior  gastroenterostomy. 
Infolding  of  ulcer.    Recovery.    Sent  by  Dr.  English,  Preswick. 

Report  October,  1910:  Has  remained  in  perfect  health 
and  has  not  required  any  treatment. 

Case  196. — D.  March  5,  1909.  J.  W.  R.,  male,  aged 
twenty-eight.  Frequent  attacks  of  pain  coming  on  one  hour 
after  food,  no  melaena  nor  haematemesis.  In  January,  1908, 
appendicectomy  performed.  The  appendix  was  found  bound 
down  by  adhesions. 

Operation:  A  large  ulcer  in  the  first  part  of  the  duodenum. 
Posterior  gastroenterostomy.  Infolding  of  ulcer.  Recovery. 
Sent  by  Dr.  Shann,  York. 

Report  October,  1910:  Feels  grand  now.  Has  gained  I 
stone  5  lbs.     Doing  ordinary  work  as  fireman  on  the  railway. 

Case  197. — D.  March  5,  1909.  R.  B.,  male,  aged  thirty- 
eight.  Four  years'  history.  Pain  two  hours  after  food.  Vom- 
iting for  the  last  two  years.  Gastric  lavage  for  twelve  months. 
Occasional  melaena. 

Operation:  A  large  duodenal  ulcer  causing  definite  obstruc- 
tion. Gastro-enterostomy.  Ulcer  infolded.  Recovery.  Sent 
by  Dr.  Edmondson,  Lancaster. 

Report  October,  1910:  Perfectly  healthy.  Gained  l}4 
stone.     Says  "I  don't  know  that  I  have  a  stomach." 

Case  198. — D.  March  12,  1909.  W.  J.,  male,  aged 
twenty-seven.  Fourteen  years'  history.  Last  few  years 
very  much  worse,  pain  daily  for  the  last  four  months.  No 
haematemesis;  melaena  two  months  ago. 

Operation:  Ulcer  just  beyond  pylorus.  Posterior  gastro- 
enterostomy. Ulcer  infolded.  Recovery.  Sent  by  Dr.  Bailey, 
Horsforth. 

Report  October,  1910:  Present  condition  quite  well.  Con- 
siderable increase  in  weight. 

Case  199. — D.  March  13,  1909.  A.  S.,  male,  aged  twenty- 
six.  Pain  three  hours  after  food  for  about  eight  years.  Much 
worse  last  six  months.  History  of  melaena,  but  no  haematem- 
esis. 

Operation:  Two  ulcers  a  short  distance  beyond  the  pylorus. 
Posterior  gastro-enterostomy.  Ulcers  infolded.  Sent  by  Dr. 
Henderson,  Oldham. 


Detailed  Statement  of  Cases  Operated  Upon  435 

Report  October,  1910:  Is  in  perfect  health.  Eats  any- 
thing;  gained  2  stone  in  weight. 

Case  200. — D.  March  19,  1909.  M.  A.,  female,  aged 
forty-five.  Several  years'  history  of  pain  coming  one  hour 
after  food.  Considerable  vomiting.  On  fluid  diet  for  the  last 
few  months. 

Operation:  A  large  duodenal  ulcer  with  much  induration 
and  adhesion  to  the  gall-bladder  just  beyond  pylorus.  Poste- 
rior gastroenterostomy.  Pylorus  infolded.  Recovery.  Sent 
by  Dr.   Archbold   Smith,    Headingley. 

Report  October,- 1910:  Is  quite  well;  has  gained  in  weight; 
no  recurrence  of  pain. 

Case  201. — D.  March  26,  1909.  J.  L.,  male,  aged  forty. 
Fifteen  years'  typical  history  of  pain.  No  haematemesis  nor 
melaena  nor  vomiting. 

Operation:  Duodenal  ulcer.  Posterior  gastroenterostomy. 
Infolding.     Recovery.     Sent  by  Dr.  Hall,  Lancaster. 

Report  October,  1910:  In  very  good  health.  Has  gained 
1 3^  stone.     No  recurrence  of  pain. 

Case  202. — D.  March  26,  1909.  H.  McN.,  male,  aged 
thirty-six.  Two  and  one-half  years'  history  of  attacks  of 
pain,  recently  more  frequent  and  severe,  no  vomiting. 

Operation :  Extensive  adhesions  of  omentum  to  anterior 
abdominal  wall.  A  large  duodenal  ulcer.  Posterior  gastro- 
enterostomy, infolding.    Recovery.   Sent  by  Dr.  Clarke,  Leeds. 

Report  October,  1910:  In  excellent  health.  Is  gradually 
gaining  weight.     No  recurrence  of  pain. 

(  !ase  203. — G.  &  D.  J.  W.  \\\,  male,  aged  fifty.  Eighteen 
months'  history,  much  more  severe  lately,  considerable  loss 
in  weight. 

Operation:  A  large  ulcer,  three  inches  on  proximal  side  of 
pylorus.  Considerable  induration,  hour-glass  contraction  of 
stomach.  Another  ulcer  in  the  first  part  of  the  duodenum. 
Posterior  gastro-enterostomy  into  the  proximal  pouch.  Re- 
covery.    Senl   by  Dr.  Thomas,   Boroughbridge. 

Report  October,  [910:  Much  improved  and  never  had 
any  pain  since  operation.  Can  take  ordinary  diet  and  has 
gained  weight .     No  vomil  ing 

Case  204.     I).     April    2,    [909.      D.,    male,   aged    forty- 


436  Duodenal  Ulcer 

nine.  Ten  or  fifteen  years'  history.  Five  years  ago  a  severe 
attack  of  melaena.  Since  then  scarcely  ever  well.  Always 
worse  in  winter;  numerous  attacks  of  melaena  and  one  attack 
of  haematemesis. 

Operation:  A  puckered  and  indurated  ulcer  on  anterior 
surface  of  duodenum.  A  second  ulcer  on  corresponding  aspect 
of  posterior  wall.  Posterior  gastro-enterostomy.  Duodenum 
infolded.     Recovery.     Sent  by  Dr.  Arnison,  Brighouse. 

Report  October,  1910:  Present  condition  very  satisfactory. 
Gained  5  lbs.  in  weight.  No  recurrence  of  pain.  Stronger 
and  better  than  for  some  years.  Occasional  flatulence  after 
a  heavy  meal. 

Case  205. — D.  April  3,  1909.  C,  female.  Several 
years'  history  of  attacks  of  pain  and  flatulence  after  meals, 
with  periods  of  complete  freedom.  During  last  fifteen  months 
numerous  attacks  of  acute  pain  in  right  hypochondrium  and 
scapular  region,  accompanied  by  much  retching  and  occasional 
vomiting.  No  history  of  jaundice.  A  diagnosis  of  gall-stones 
was  made. 

Operation:  Gall-bladder  and  ducts  apparently  normal.  On 
the  anterior  surface  of  first  part  of  the  duodenum  a  large 
puckered  ulcer  causing  considerable  constriction.  Posterior 
gastro-enterostomy.  Infolding.  Recovery.  Sent  by  Dr. 
Wedge  wood,  York. 

Report  August,  191 1 :   "  Perfectly  well." 

Case  206. — D.  April  15,  1909.  T.,  male,  aged  forty-six. 
Twenty-six  years'  history.  At  age  of  twenty-three  a  severe 
attack  of  haematemesis  and  melaena.  Since  then  three  or 
four  similar  attacks.  Has  used  a  stomach-tube  for  the  last 
five  years  with  some  relief.  Three  weeks  ago  another  severe 
attack  of  haemorrhage. 

Operation:  Duodenum  adherent  to  gall-bladder  and  liver, 
numerous  scars  of  ulceration,  lesser  sac  partially  obliterated 
by  adhesions;  probably  a  subacute  perforation  at  one  time. 
Posterior  gastro-enterostomy.  Infolding.  Recovery.  Sent 
by  Dr.  R.  S.  Young,  Eccles. 

Report  October,  1910:  Is  in  better  health  than  he  has 
been  since  boyhood.     Has  gained  i^  stone  in  weight. 

Case  207.  — G.  &  D.    April  22,  1909.    C,  male,  aged  forty- 


Detailed  Statement  of  Cases  Operated  Upon  437 

three.  Twenty  years'  history;  attacks  always  occurred  in 
winter  months.  Vomiting  of  acid  mucus;  fifteen  years  ago 
an  attack  of  haematemesis  and  melaena.  Three  weeks  ago  a 
second   attack  of  haematemesis. 

Operation:  A  small  scar  of  an  ulcer  exactly  at  pylorus. 
Three-fourths  of  art  inch  beyond  the  pylorus  a  hard  indurated 
and  puckered  ulcer.  Posterior  gastroenterostomy.  Infold- 
ing.    Recovery.    Sent  by  Dr.  Modlin,  Sunderland. 

Report  October,  1910:  In  perfect  health.  Has  gained 
9  lbs.  in  weight.     No  recurrence  of  pain  nor  vomiting. 

Case  208. — D.'  April  30,  1909.  W.  B.,  male,  aged  thirty- 
two.  Eleven  years'  history.  For  last  five  years  has  used 
stomach-tube.  Five  months  ago  severe  attack  of  haemateme^ 
and  melaena. 

Operation:  A  large  duodenal  ulcer.  Posterior  gastroenter- 
ostomy.   Infolding.  Recovery.    Sent  by  Dr.  Hawkyard,  Leeds. 

Report  October,  1 9 10:  Looks  very  well.  Gained  in  weight. 
No  pain  after  food.     Is  now  doing  his  ordinary  work. 

Case  209. — D.  April  30,  1909.  B.  S.,  male,  aged  sixty. 
Many  years'  history  of  pain  two  to  three  hours  after  food. 
Worse  during  last  four  years.  An  attack  of  haematemesis 
and  melaena  twelve  months  ago.    Has  lost  2  stone  in  weight. 

Operation:  Two  duodenal  ulcers  on  anterior  surface.  Pos- 
terior gastro-enterostomy.  Infolding.  Sent  by  Dr.  Matthews, 
Holmfirth. 

Report  October,  1910:  Present  condition  very  good.  Has 
gained  more  than  a  stone.  Success  of  the  operation  has  been 
remarkable. 

Case  210. — D.  May  10,  1909.  G.  B.,  male,  aged  forty- 
nine.  Eight  or  ten  years'  history  of  indigestion,  pain  two  hours 
after  meals,  relieved  by  food.  Very  severe  attack  of  pain 
and  vomiting  one  month  ago,  with  melaena. 

Operation:  An  ulcer  in  the  first  part  of  the  duodenum. 
The  peritoneal  surface  was  dotted  with  miliary  tubercles. 
The  nicer  was  thought  to  be  tuberculous.  Posterior  gastro- 
enterostomy! Infolding.  Recovery.  Senl  by  Dr.  Blair, 
1  [elmsley. 

Report  October,  l<»lo:  1. 00k-  .iml  feels  better  than  he  has 
done  for  years.     Has  gained  1 '  .•  stone.     Nine  months  ago  an 


438  Duodenal  Ulcer 

attack  of  abdominal  pain  with  some  pyrexia.  Now  all  right 
again. 

Case  211. — D.  May  15,  1909.  C.  H.,  male,  aged  fifty- 
three.  Twenty-nine  years'  history.  Much  worse  during  last 
two  years.     No  haematemesis  nor  melaena. 

Operation:  •  An  ulcer  in  the  beginning  of  the  second  part  of 
the  duodenum ;  adhesions  to  under  surface  of  liver.  Posterior 
gastroenterostomy.  Infolding.  Sent  by  Dr.  Wilson,  Old- 
ham. 

Report  October,  1910:  Better  than  for  seven  years. 
( Gained  1 1  lbs.  in  weight.    Has  not  required  medical  treatment. 

(asp:  212. — D.  May  21,  1909.  W.  J.  B.,  male,  twelve 
months'  history.  Occasional  vomiting,  one  attack  of  haemat- 
emesis  and  melaena. 

Operation:  Two  ulcers  just  beyond  pylorus,  one  on  supe- 
rior surface  and  adherent  to  the  liver,  the  other  on  posterior 
wall  adherent  to  pancreas.  Posterior  gastro-enterostomy. 
Infolding. 

Report:    Cannot  be  obtained. 

Case  213. — D.  June  11,  1909.  P.,  female,  aged  forty- 
five.  For  nearly  thirty  years  attacks  of  pain  and  flatulence 
a  short  time  after  food.  During  last  year  pain  more  severe 
and  always  three  hours  after  food. 

Operation:  A  puckered  and  indurated  ulcer  just  beyond 
the  pylorus.  Posterior  gastro-enterostomy.  Infolding.  Re- 
covery.   Sent  by  Dr.  Awburn,  Mottrom. 

Report  October,  1910:  Present  condition  satisfactory. 
No  pain  nor  vomiting. 

Case  214. — D.  June  19,  1909.  E.  C,  female,  aged  thirty- 
nine.  Five  years'  history.  Three  attacks  of  haematemesis 
and  melaena.     On  fluids  for  six  months. 

Operation:  Large  crateriform  ulcer  on  posterior  aspect  of 
duodenum.  Posterior  gastro-enterostomy.  Duodenum  in- 
folded.    Recovery.     Sent  by  Dr.  Roberts,  Brighouse. 

Report  October,  1910:  Has  gained  more  than  3  stone  in 
weight.  No  recurrence  of  pain,  no  vomiting.  The  extreme 
anaemia  has  disappeared. 

Case  215. — D.  June  19,  1909.  M.  B.,  male,  aged  twenty- 
six.     Twelve   months'   historv.      Pain   two  hours  after  food, 


Detailed  Statement  of  Cases  Operated  Upon  439 

relieved  by  next  meal.  Some  vomiting,  acid  eructations. 
Xo  haematemesis  nor  melaena. 

Operation:  A  small  ulcer  on  anterior  aspect  of  duodenum. 
Excision  of  ulcer.    Recovery.    Sent  by  Dr.  Woodcock,  Leeds. 

Report  October,  1910:  Present  condition  excellent.  Great 
gain  in  weight;  occasional  discomfort  at  times,  easily  relieved 
by  carbonates. 

Case  216. — D.  June  19,  1909.  T.  B.,  male,  aged  forty- 
four.  Seven  years' history  of  attacks  of  pain.  Vomiting.  No 
haematemesis  nor  melaena.  Has  used  stomach-tube  for  six 
years. 

Operation:  A  large  ulcer  on  anterior  surface  of  duodenum, 
many  adhesions  binding  duodenum  to  under  surface  of  liver. 
Posterior  gastroenterostomy.  Pylorus  infolded.  Sent  by 
Dr.  Xormington,  Nelson. 

Report  October,  1910:  Present  condition  good.  Gained 
weight,  no  recurrence  of  pain  nor  vomiting.  Patient  very 
well  and  sorry  he  did  not  have  operation  sooner. 

Case  217. — D.  June  20,  1909.  Dr.  L.,  male,  aged  thirty. 
At  nine  years  of  age  was  kicked  in  stomach  and  vomited  at 
intervals  for  twenty-four  hours.  Since  that  time  has  been 
liable  to  attacks  of  pain  two  and  one-half  hours  after  food  at 
varying  intervals.    No  melaena  noticed.    Induces  vomiting. 

Operation:  Two  ulcers  in  first  part  of  duodenum;  the  peri- 
toneal surface  over  one  of  these  was  red  and  inflamed.  Pos- 
terior gastroenterostomy.     Infolding.     Recovery. 

Report  October,  1910:  "My  present  condition  may  be 
summed    up   in   one   word — 'perfect.'" 

Case  218. — D.  July  12,  1909.  Mr.  M.,  male,  aged  fifty- 
eight.  Thirty  to  turn-  years'  history.  Pain  always  worse  in 
(old  weather.  Much  worse  last  three  years.  Haematemesis; 
melaena.     Lost  2Y2.  stone. 

Operation:  Firsl  inch  of  duodenum  scarred  by  old  ulcera- 
tion. Posterior  gastroenterostomy.  Enfolding.  Recovery. 
Sent  by  I  >r.  McNabb,  Withern. 

Report  October,  1910:  Says  he  is  better  than  he  has  been 
for  the  lasl  twenty  years.  Gained  1  '  _>  stone.  No  pain  nor 
vomiting. 

Case  219.     I>.    Jul)  22,  [909.     E.  !'»..  male,  aged  twenty- 


440  Duodenal  Ulcer 

seven.  Ten  years'  history.  Chill  often  brings  on  attack. 
Never  vomited,  no  melaena. 

Operation:  Large  duodenal  ulcer  one  inch  from  pylorus. 
Posterior  gastroenterostomy.  Infolding.  Recovery.  Sent 
by  Dr.  Ellis,  Halifax. 

Report  October,  1910:  Never  sounder  in  his  life.  Patient 
is  delighted  with  the  result  of  the  operation. 

Case  220. — D.  August  21,  1909.  A.  A.,  male,  aged  forty. 
Present  attack  has  lasted  ten  months.  A  previous  attack 
four  years  ago.  Occasional  vomiting.  No  relief  from  medical 
treatment. 

Operation:  Ulcer  on  anterior  aspect  of  duodenum.  Poste- 
rior gastro-enterostomy.  Infolding.  Recovery.  Sent  by  Dr. 
Harrowell,  Leeds. 

Report  August,  191 1:     "Result  very  good." 

Case  221. — D.  August  21,  1909.  J.  N.,  aged  forty-six. 
Nine  years'  history,  attacks  in  spring  and  autumn.  Attack 
of  haematemesis  and  melaena  a  month  ago. 

Operation:  Large  duodenal  ulcer.  Posterior  gastro-enter- 
ostomy.    Infolding.     Sent  by  Dr.  Clarke,  Doncaster. 

Report:  Quite  well.  Better  in  health  than  for  six  or  eight 
years.    Not  lost  a  day's  work  since. 

Case  222. — D.  August  27,  1909.  H.  S.,  male,  aged  thirty- 
six.  Since  boyhood  has  been  troubled  with  regurgitation  of 
food  from  stomach,  this  much  worse  during  last  three  years. 
No  pain  until  ten  months  ago,  since  then  pain  two  hours 
after  food,  relieved  by  food. 

Operation:  Ulcer  just  beyond  pylorus.  Posterior  gastro- 
enterostomy. Infolding.  Recovery.  Sent  by  Dr.  Alexander, 
Barrow. 

Report  October,  1910:  Patient  feels  much  better  since  the 
operation.  Vomiting  every  three  or  four  days  or  a  week- — 
sometimes  a  month  intervenes  but  no  longer.  It  is  yellowish- 
green  and  bitter,  comes  on  every  half  an  hour  after  meals. 
If  patient  rests  after  a  meal,  vomiting  is  sure  to  come  on. 
Amount  of  vomit  about  half  a  teacupful.  Patient  has  a 
heavy  feeling  in  region  of  stomach,  especially  after  food. 
Has  a  good  appetite  and  can  eat  all  kinds  of  food.  He  says 
it  is  mostly  liquids  that  are  vomited  and  not  food. 


Detailed  Statement  of  Cases  Operated  Upon  441 

Further  report,  September  10,  191 1 :  Dr.  Alexander  writes: 
"This  man  says  his  condition  is  practically  the  same  as 
previously  reported.  There  is  no  pain,  but  a  'weary'  feeling 
in  stomach.  He  always  has  a  good  appetite,  is  sick  at  inter- 
vals varying  from  a  few  days  to  a  week.  The  vomit  is  yel- 
lowish-green, and  usually  consists  of  food  in  a  liquid  form.  It 
occurs  between  one  or  two  hours  after  a  meal,  most  often 
after  tea  at  5.30  p.  m.,  but  also  after  the  other  meals.  Diet 
has  little  effect  upon  the  vomiting,  except  eggs,  which  he 
thinks  make  him  worse.  The  bowels  are  still  constipated. 
His  weight  is  about  the  same  as  before  the  operation,  and  he 
looks  well.  He  feels  much  better  in  general  health  since  the 
operation,  but  expresses  himself  as  willing  to  undergo  any 
further  treatment  to  stop  the  vomiting." 

Case  223. — D.  August  27,  1909.  J.  R.,  male,  aged  fifty- 
one.     Three  years'  history.     Typical  attacks  of  pain. 

Operation:  A  large  duodenal  ulcer,  adherent  posteriorly. 
Posterior  gastro-enterostomy.  Duodenum  infolded.  Re- 
covery.   Sent  by  Dr.  Andrews,  Burmantofts. 

Report  August,  191 1:     "Perfectly  well." 

Case  224. — G.  &  D.  August  28,  1909.  Mr.  R.,  aged 
seventy.  Ten  years'  history.  Six  months  ago  haematemesis. 
Worse  in  winter. 

Operation:  Large  ulcer  on  lesser  curvature  passing  into 
duodenum.  Whole  mass  the  size  of  a  five-shilling  piece  with 
crater  size  of  florin.  Posterior  gastro-enterostomy.  Pylorus 
closed;   ulcer  infolded.     Sent  by  Dr.  Bruce  Kelly,  Burnham. 

Report  October,  1910:  Since  operation  has  had  no  pain. 
Better  in  health  than  for  several  years.  Gained  greatly  in 
weight. 

Case  225. — D.  September  2,  1909.  D.  S.  P.,  male,  aged 
thirty-one.  Two  years  ago  haematemesis  and  melaena;  pre- 
vious to  this  vague  abdominal  pain-.  Since  then  has  had 
frequent  haematemesis  and  melaena.     Pain  insignificant. 

Operation:     Patient   collapsed  alter  abdominal  incision  as 
result  of  duodenal  haemorrhage.     Much  scarring  of  first  one 
and  one-halt  inches  of  duodenum.     1  'lee  rated  area  excised.     Pos 
terior  gastro-enterostomy.     Recovery.     Seni   by  Dr.  Galletly, 
Bourne. 


442  Duodenal  Ulcer 

Report  October,  1910:  Feels  very  fit.  '  Takes  ordinary 
food.  Two  slight  attacks  of  pain  due  to  indiscretion  in  diet. 
Enjoys  outdoor  exercise,  but  weight  has  not  increased  much. 

CASE  226. — G.  &  D.  September  3,  1909.  E.  B.,  female, 
aged  thirty-three.  Ten  years'  history,  pain  immediately 
after  meals,  vomiting.  On  Benger's  food  and  milk  for  two 
years.  Last  year  rather  better,  but  severe  pain  returned 
seven  weeks  ago.    No  heematemesis. 

Operation:  Stomach  dilated.  On  anterior  surface  a  gastric 
ulcer  extending  across  pylorus  into  duodenum;  on  posterior 
surface  a  small  ulcer  on  gastric  side  of  pylorus.  Posterior 
gastro-enterostomy.  Anterior  ulcer  infolded.  Recovery. 
Sent  by  Dr.  Williamson,  Hull. 

Report  August  28,  1911 :  "I  am  pleased  to  say  I  am  much 
better  since  the  operation,  but  I  still  take  the  medicine  given 
me  on  leaving  the  Infirmary. 

Case  227. — G.  &D.  September,  1909.  A.  F.  W.,  female, 
aged  thirty-eight.  Suffered  from  indigestion  all  her  life.  Pain 
immediately  after  food,  lasts  about  an  hour.  Vomiting. 
Three  weeks  ago  hsematemesis. 

Operation:  Gastric  ulcer  on  lesser  curvature  near  cardia 
with  commencing  hour-glass  contraction.  Duodenal  ulcer 
just  beyond  pylorus.  Gastro-gastrostomy  and  posterior 
gastro-enterostomy  into  distal  pouch.  Recovery.  Sent  by 
Dr.  Orford,  Pontefract. 

Report:  This  patient  has  left  the  district  and  cannot  be 
traced. 

Case  228. — D.  Cholelithiasis.  September, .  1909.  E.  A., 
female.  Indigestion  ever  since  she  can  remember,  certainly 
since  the  age  of  thirteen.  Pain  at  first  one  hour  after  meals, 
occasionally  relieved  by  vomiting.  Four  years  ago  began  to 
suffer  from  haematemesis;  since  that  time  pain  later  in  onset 
and  relieved  by  food.     Four  attacks  of  hsematemesis. 

Operation:  Ulcer  about  the  size  of  a  shilling  just  beyond 
pylorus.  Posterior  gastro-enterostomy.  Ulcer  infolded. 
Appendix  slightly  bulbous,  but  not  adherent.  Appendicec- 
tomy.  Gall-bladder  enlarged;  a  calculus  impacted  in  cystic 
duct.  Cholecystectomy.  Gall-bladder  contained  clear  mucus 
and  5  stones.    Recovery.    Sent  by  Dr.  Carse,  Rochdale. 


Detailed  Statement  of  Cases  Operated  Upon  443 

Report  October,  1910.  Patient  much  improved  in  appear- 
ance and  her  capacity  for  work.  Able  to  eat  ordinary  food 
without  discomfort.  Gain  in  weight.  No  recurrence  of  pain. 
The  operation  has  had  an  entirely  satisfactory  result. 

Case  229. — D.  September,  1909.  A.  L.,  female,  aged 
thirty-one.  Nine  years'  history.  Five  attacks  of  hsematem- 
esis. 

Operation:  Two  ulcers  on  anterior  aspect  of  duodenum, 
another  on  posterior  wall  exactly  opposite.  Posterior  gastro- 
enterostomy. Infolding.  Recovery.  Sent  by  Dr.  Longley, 
Saltburn. 

Report  October,  1910:  Xo  pain  at  any  time;  gained  in 
weight.  If  she  eats  too  quickly,  is  likely  to  vomit,  but  there 
is  no  feeling  of  nausea.  Patient  is  entirely  satisfied  with  result 
of  operation. 

Case  230. — D.  October  4,  1909.  Mrs.  F.,  aged  fifty-four. 
Twelve  years'  history;  pain  one  hour  after  food.  Recently 
vomiting  of  large  quantities  of  material.  Palpable  tumour, 
dilated  stomach,  visible  peristalsis. 

Operation:  Large  inflammatory  mass  in  duodenum,  involv- 
ing pylorus,  fixed  to  liver.  Posterior  gastroenterostomy. 
Recovery.    Sent  by  Dr.  Beattie,  Stockton-on-Tees. 

Report  October,  1910:  Present  condition  much  improved. 
Has  vomited  bile  once  or  twice. 

Case  231. — D.  October  7,  1909.  Nurse  E.  Nine  years1 
history.  No  vomiting.  Pain  constant,  two  to  three  hours 
after   food. 

Operation:  Large  duodenal  ulcer  on  anterior  wall,  another 
posteriorly.  Posterior  gastroenterostomy.  Infolding.  Re- 
covery.    Sent  by  Dr.  Wickham,  Newport  Pagnell. 

Report  October,  1910:  Patient  in  good  health,  gained 
weight.     Some  flatulence  and  palpitation. 

Case  232. —  I).  October  23.  1000.  1  >r.  A.,  aged  thirty- 
seven.  Indigestion  always.  "Hunger  pain"  marked  for 
lasl  eighl  years.    Two  years  ago  severe  attack  with  vomiting. 

Operation:  Well-marked  ulcers  on  anterior  and  posterior 
aspects  of  duodenum,  one- hall'  inch  beyond  pylorus.  Posterior 
gastro-enterostomy.     Infolding.     Reco\  erj . 

Reporl  October,   [910:     "In  excellenl  health     better  than 


444  Duodenal  Ulcer 

I  remember  being  previous  to  operation.  Xo  recurrence  of 
pain.     Some  flatulence  after  meals  at  times." 

Case  233. — D.  October  29,  1909.  H.  B.  F.,  male,  aged 
thirty-nine.  Ten  years'  history.  Attacks  worse  in  winter; 
no   vomiting. 

Operation:  Large  indurated  area  of  ulceration  in  first  part 
of  duodenum.  Posterior  gastroenterostomy.  Infolding.  Re- 
covery.    Sent  by  Dr.  Smith,  New  Wortley. 

Report  October,  1910:  Dr.  Smith  writes:  "Respecting 
your  request  for  particulars  of  my  patient,  Mr.  F.,  on  whom 
you  performed  a  gastroenterostomy,  I  regret  to  say  that  he 
committed  suicide  by  drowning,  owing  to  business  and  family 
worries,  about  eight  weeks  ago.  I  saw  him  just  before  his 
death  and  he  said  his  health  was  better  than  it  had  ever  been 
previously.  He  was  just  returning  from  a  ten-mile  walk  in 
the  country,  and  did  not  feel  in  the  least  exhausted.  He  had 
put  on  a  considerable  amount  of  flesh  and  had  taken  ordinary 
food  without  any  pain  or  inconvenience  whatever.  I  think 
you  may  take  it  that  the  operation  was  an  absolute  success." 

Case  234. — D.  October,  1909.  J.  B.,  male,  aged  thirty- 
two.  Two  and  one-half  years'  history.  Worse  in  cold  weather. 
No  vomiting.     No  melsena. 

Operation:  Large  indurated  ulcer  size  of  a  walnut  just 
beyond  pylorus;  scars  of  several  other  smaller  ones.  Posterior 
gastro-enterostomy.  Infolding.  Recovery.  Sent  by  Dr. 
Hard  wick,  Snainton. 

Report  October,  1910:  In  good  health;  gained  weight. 
It  was  some  weeks  before  quite  free  from  pain,  but  this  was 
not  his  former  "hunger  pain."  I  thought  it  was  possibly  due 
to  his  journey  soon  after  operation.  Now  appears  in  robust 
health. 

Case  235. — D.  November  18,  1909.  W.  S.,  male,  aged 
thirty-two.  Three  and  one-half  years'  history.  Lost  about 
1 3^2  stone.    Seldom  vomits;   no  melsena. 

Operation:  A  duodenal  ulcer  with  red,  shaggy  peritoneal 
surface  in  first  part  of  duodenum.  The  peritoneal  cavity 
below  level  of  greater  curvature  of  stomach  was  obliterated 
by  adhesions,  but  the  first  loop  of  the  jejunum  was  separated 
with    difficulty   and    the    usual    posterior   gastro-enterostomy 


Detailed  Statement  of  Cases  Operated  Upon  445 

performed.     Ulcer  infolded.     Recovery.    Sent  by  Dr.  Hughes. 
York. 

Report  October,  1910:  Condition  on  whole  very  satis- 
factory; tendency  to  indigestion  if  not  careful  with  diet. 
Gained  12  lbs.  in  weight.  No  recurrence  of  old  acute  pain,  but 
occasional  pain  in  back  and  shoulders. 

Case  236.— D.  December  9,  1909.  Mr.  T.,  aged  fifty- 
nine.  Typical  history  of  pain  for  twenty  years.  During  last 
four  years  much  worse;  during  this  time  has  been  mainly 
living  on  a  fluid  diet;  recently  frequent  vomiting  of  consider- 
able quantities  of  stomach  contents.  No  history  of  hsemat- 
emesis  or  melsena. 

Operation:  Duodenum  converted  into  a  series  of  pouches 
by  ulceration;  lumen  in  one  place  much  narrowed.  Posterior 
gastroenterostomy.  Infolding.  Recovery.  Sent  by  Dr. 
Fletcher,  Dronfield. 

Report  October,  1910:  Says  he  is  better  now  than  for 
many  years.     Slight  gain  in  weight;  is  now  able  to  work. 

Case  237. — D.  December  31,  1909.  W.  R.,  male,  aged 
forty-eight.  Thirteen  years'  history  of  attacks  of  pain,  worse 
in  winter.  Two  attacks  of  melsena,  one  of  haematemesis  and 
melaena. 

Operation:  Ulcer  one  inch  beyond  pylorus.  Posterior 
gastroenterostomy.  Infolding.  Recovery.  Sent  by  Dr. 
Daniel,  Barrow. 

Report  October,  1910:  Present  condition  excellent.  Says 
he  does  not  think  he  could  feel  better  than  he  does.  Enjoys 
his  food  and  takes  anything. 

CASE  238. — D.     December  31,    1909.     A.   D..   male 
forty-three.     Twenty  years'   history.     Pain  sometimes  very 
acute.    Vomiting  occasionally.    No  haematemesis  nor  melaena. 

Operation:  Large  duodenal  ulcer  adherent  to  liver  and 
^all-bladder.  Some  adhe>ion>  to  anterior  abdominal  wall. 
No  gall-stones.  Posterior  gastroenterostomy.  Infolding 
of  ulcer.     Recovery.    Sent  by  Dr.  Edwards,  Huddersfield. 

Report  October,  1910:  Practically  quite  well.  Gain  in 
weight.  Slight  indigestion  once  Quite  a  differenl  man  since 
operation! 

Case  239. — D.     December  31,   [909.     F.  \\\,  male. 


446  Duodenal  Ulcer 

forty-one.  Thirteen  years'  history.  One  severe  hacmatemesis ; 
no  history  of  melaena. 

Operation:  An  ulcer  one  inch  from  pylorus,  adherent  to 
pancreas;  duodenum  kinked  and  pouched.  Posterior  gastro- 
enterostomy. Pylorus  infolded.  Recovery.  Sent  by  Dr. 
Elvins,  York. 

Report  May,  1911:  Present  condition  excellent.  Gained 
12  lbs.     No  pain  nor  vomiting. 

Case  240. — G.  &  D.  December  31,  1909.  W.  C.,  male, 
aged  thirty-two.  Three  years'  history.  Occasional  vomiting. 
No  haematemesis  nor  melaena. 

Operation:  A  large  ulcer  adherent  to  under  surface  of  liver; 
this  involved  pylorus  and  extended  both  into  stomach  and 
duodenum.  Posterior  gastroenterostomy.  Infolding.  Sent 
by  Dr.  Elliott,  Cudworth. 

Report  October,  1910:  Condition  very  good.  No  recur- 
rence of  pain  whatever,  can  take  anything. 

Case  241. — D.  January  24,  1910.  A.  S.,  male,  aged 
thirty-seven.     Ten  years'  history. 

Operation:  Large  ulcer  on  anterior  surface  of  duodenum 
with  a  deep  pucker.  Posterior  gastro-enterostomy.  Infold- 
ing. Recovery.  Seen  and  operated  upon  at  Liverpool  with 
Dr.  Blair-Bell. 

Report  May,  191 1:  Present  condition  satisfactory;  has 
had  a  little  trouble  with  flatulence,  but  pain  not  of  same  char- 
acter nor  anything  like  so  acute  as  before  operation.  I 
consider  him  immensely  better. 

Case  242. — D.  January  25,  1910.  G.  W.  W.,  male,  aged 
twenty-five.  Nine  years'  history.  Frequent  vomiting.  No 
hacmatemesis  nor  melaena. 

Operation:  Large  ulcer  on  posterior  aspect  just  beyond 
pylorus.  Posterior  gastro-enterostomy.  Infolding.  Recovery. 
Sent  by  Dr.  Dearden,  Wyke. 

Report  May,  1911 :    Is  in  the  best  of  health.     No  symptoms. 

Case  243. — D.  January  27,  1910.  Mr.  C,  male,  aged 
sixty-three.  Indigestion  for  forty  years.  Severe  attacks  of 
pain  for  fourteen  years.  For  last  thirteen  years  has  washed 
out  his  stomach  three  times  a  day.  If  this  is  neglected,  he 
vomits  large  quantities  of  yeasty  fluid. 


Detailed  Statement  of  Cases  Operated  Upon   447 

Operation:  Enormously  dilated  stomach.  Scarring  of  old 
ulceration  in  duodenum,  with  pouching.  Pylorus  very  nar- 
row. Posterior  gastroenterostomy.  Infolding.  Recovery. 
Sent  by  Dr.  Roberts,  Garstang. 

Report  May,  191 1 :  Never  had  such  health  for  over  twenty 
years.  Gained  30  lbs.  in  weight.  No  recurrence  of  pain  nor 
vomiting. 

Case  244. — D.  January  28,  1910.  J.  P.,  male,  aged  forty- 
three.  Twenty-three  years' history.  Several  attacks  of  hsemat- 
emesis  and  melaena. 

Operation:  Scarring  of  several  ulcers  just  beyond  pylorus. 
Narrowing  and  pouching  of  duodenum.  Posterior  gastro- 
enterostomy. Infolding.  Recovery.  Sent  by  Dr.  Ferguson, 
Keighley. 

Report  May,  1911:  Present  condition  excellent.  No 
pain  nor  vomiting.  Says  he  has  not  had  a  day's  illness  since 
he  returned. 

CASE245. — D.  January  29,  1910.  Dr.  W.  S.,  male.  Attacks 
of  painful  indigestion  since  age  of  twenty.  Six  years  ago  a 
violent  attack  of  pain;  if  not  actual  perforation,  was  severe 
enough  to  have  been  so.  In  bed  a  month,  and  off  work  three 
months. 

Operation:  Duodenum  buried  in  mass  of  adhesions;  clearly 
an  old  perforation;  adhesions  separated;  duodenum  a  mass  of 
scars  and  cartilaginous  to  the  feel.  Posterior  gastroenteros- 
tomy.    Ulcerated  area  infolded  with  difficulty.     Recovery. 

Report  May,  191 1:  Gained  12  lbs.  "No  symptoms  of 
stomach  trouble  whatever,  and  I  can  eat  anything." 

Case  246. — D.  January  29,  1910.  Mr.  W.  Four  to 
five  years'  history.  Never  vomits.  Anxiety,  cold  weather,  or 
hard  work  always  liable  to  bring  on  an  attack. 

Operation:  Large  duodenal  ulcer  on  anterior  wall,  surface 
depressed,  pale,  and  hard.  Posterior  gastro-enterostomy. 
Infolding.     Recovery.     Sent  by  1  )r.  Steele,  Middlcsboro. 

Report  May,  1911:  In  excellent  health,  gained  7  lbs. 
A  completely  successful  case. 

Case  247.  I).  Februarj  3,  [910.  Rev.  E.,  male,  aged 
fifty-five.  Twenty-five  years'  history.  Six  years  ago  much 
worse.     Mel, en, 1  ,ind  ha?matemesis. 


448  Duodenal  Ulcer 

Operation:  Duodenum  a  mass  of  scars  with  numerous 
adhesions.  Posterior  gastroenterostomy.  Infolding.  Re- 
covery.    Sent  by  Dr.  Jefferson,  Rochdale. 

Report  May,  191 1:  In  quite  good  health.  No  recurrence 
of  pain  nor  vomiting.     Patient  is  very  grateful. 

Case  248. — D.  February  12,  1910.  Mr.  G.,  male,  aged  fifty. 
Indigestion  ever  since  age  of  fourteen.  Much  worse  last 
twelve  months.     Profuse  melaena  six  weeks  ago. 

Operation:  Multiple  duodenal  ulcers,  much  scarring.  Pos- 
terior gastro-enterostomy.  Infolding.  Recovery.  Sent  by 
Dr.  Gillibrand,  Bolton. 

Report  May,  1911:  In  good  general  health.  There  is  a 
good  deal  of  post-operative  neurasthenia;  for  a  long  time 
complained  of  colicky  pain  associated  with  constipation. 
Since  resuming  horse  exercise  has  been  much  better.  Takes 
ordinary  mixed  diet  in  good  quantity. 

(ask  249. — D.  February  14,  1910.  J.  G.,  male,  aged 
sixty-three.  Four  years'  history.  Melaena  eighteen  months 
ago.     Severe  haematemesis  and  melaena  six  months  ago. 

Operation:  Very  vascular  and  partially  indurated  scar  of 
ulcer  in  first  part  of  duodenum;  from  this  a  band-like  adhesion 
ran  up  to  base  of  gall-bladder.  Appendix  long  and  club- 
shaped.  Posterior  gastro-enterostomy.  Infolding.  Appen- 
dicectomy.     Recovery.     Sent  by  Dr.  Eastes,  Folkestone. 

Report  July,  191 1 :    Very  well,  indeed. 

Case  250. — D.  February  15,  1910.  T.  H.,  male,  aged 
thirty-eight.  Indigestion  a  number  of  years.  For  last  two 
years  copious  vomiting. 

Operation:  Stomach  hypertrophied  and  greatly  dilated. 
A  large  chronic  ulcer  causing  stenosis  of  first  part  of  duodenum. 
Posterior  gastro-enterostomy.  Infolding.  Recovery.  Sent 
by  Dr.  J.  J.  Anning,  Beeston  Hill. 

Report  May,  191 1:  Gained  3  stone  in  weight.  Says  he 
is  first  class,  and  never  felt  better  in  his  life. 

Case  251. — D.  February  18,  19 10.  Mr.  P.,  male.  Fifteen 
years'  typical  history.  Recently  haematemesis  and  melaena. 
Very  violent  attack  of  pain  three  weeks  ago. 

Operation:  Scarring  of  duodenum  with  many  adhesions 
binding  it  to  liver  and  anterior  abdominal  wall;  evidently  an 


Detailed  Statement  of  Cases  Operated  Upon  449 

old  perforation.  Posterior  gastroenterostomy.  Infolding 
of  pylorus.     Recovery.    Sent  by  Dr.  Woodcock,  Leeds. 

Report  May,  1911:  Quite  well.  Regrets  operation  was 
not  done  years  ago. 

Case  252. — D.  February  25,  1910.  J.  H.,  male,  aged 
fifty-two.  Two  years'  history.  Severe  hsematemesis  twelve 
months  ago. 

Operation:  Large  ulcer,  causing  pouching  of  duodenum. 
Adhesions  to  liver  and  gall-bladder.  Posterior  gastroenter- 
ostomy. Infolding.  Adhesions  freed.  Recovery.  Sent  by 
Dr.  Knight,  Keswick. 

Report  May,  191 1:  In  good  health,  but  has  to  be  careful 
with  diet.  Gained  2j^  stone.  No  pain.  Has  vomited  occa- 
sionally, but  not  often  during  last  six  months.  Vomit  con- 
sists of  food. 

Case  253. — D.  March  3,1910.  Mr.  H.,  male,  aged  forty- 
eight.  Twenty  years'  history.  Last  three  years  very  bad. 
Vomited  large  quantities  during  last  six  months. 

Operation:  Scar  of  duodenal  ulcer  close  to  pylorus,  pro- 
ducing much  stenosis.  Stomach  much  dilated  and  hyper- 
trophied.  Posterior  gastroenterostomy.  Infolding.  Re- 
covery.    Sent  by  Dr.  Tough,  Accrington. 

Report  May,  191 1:  Feels  better  than  he  has  done  for 
many  years.  Gained  12  lbs.  No  vomiting.  Eats  and  digests 
any  sort  of  food. 

Case  254.- — D.  March  4,  1910.  E.  D.,  male,  aged  forty- 
seven.  Seventeen  years'  history.  No  haematemesis  nor 
melaena. 

Operation:  Large  ulcer  in  first  pari  of  duodenum.  Poste- 
rior gastroenterostomy.  Infolding.  Recovery.  Sunt  by 
Dr.  Robert  Trotter,  Holmfirth. 

Report,  May,  1911:  In  robust  health.  Gained  2  stone. 
Eats  any  sort  of  food  and  follows  a  fairly  labourious occupation. 

Case  255.  1).  March  12,  [910.  E.  ('..  male,  aged 
twenty-eight.  Two  years'  history.  Much  worse  lasl  time 
month-.     ( Occasional  vomiting. 

operation:  Ulcer  in  first  pari  o\  duodenum,  size  ol  hazel- 
nut.   Appendix  contained  many  concretions.     Posterior  gastro- 

29 


4^0  Duodenal  Ulcer 

enterostomy.  Infolding.  Appendicectomy.  Recovery.  Sent 
by  Dr.  Scarborough,  Leeds. 

Report  May,  1911:  Feels  as  well  and  strong  as  ever  he 
did  in  his  life.     No  recurrence  of  pain  nor  vomiting. 

Case  256. — D.  March  11,  1910.  H.  A.,  male,  aged  thirty- 
eight.    Typical  history  two  years'  duration.     No  vomiting. 

Operation:  Hard  mass  in  duodenum;  many  adhesions  to 
under  surface  of  liver.  Posterior  gastroenterostomy.  Recov- 
ery.    Sent  by  Dr.  Archbold  Smith,  Headingley. 

Report  May,  191 1:  Very  well,  indeed.  No  discomfort. 
Taking  food   well. 

Case  257. — D.  March  11,  1910.  L.  P.,  male,  aged  forty- 
seven.  Seventeen  years'  history.  Hsematemesis  eight  years 
ago,  two  other  attacks  since  that  time.     Frequent  vomiting. 

Operation:  Ulcer  just  beyond  pylorus,  causing  a  tight  sten- 
osis. Posterior  gastroenterostomy.  Infolding.  Recovery. 
Sent  by  Dr.  Adams,  Sowerby  Bridge. 

Report  May,  1911:  Better  than  he  has  been  for  years. 
Occasional  bilious  vomiting  about  once  a  month. 

Case  258. — D.  March  22,  1910.  H.  M.,  male,  aged 
thirty.  Since  a  schoolboy  has  been  in  the  habit  of  regurgitat- 
ing food  into  mouth  and  swallowing  it  again  after  further 
mastication.  Periodic  attacks  of  pain  since  age  of  sixteen. 
About  this  time  an  attack  of  "dysentery"  with  bloody  stools 
and  mucus  lasting  a  week.  Transferred  from  the  care  of  Dr. 
T.  Wardrop  Griffith. 

Operation:  Ulcer  just  beyond  pylorus;  stomach  wall 
hypertrophied.  Posterior  gastro-enterostomy.  Infolding. 
Recovery. 

Report  May,  191 1:  "Since  my  operation  my  health  has 
been  all  that  I  could  desire.  I  enjoy  any  food  that  is  put  before 
me.     I  am  a  new  man  now." 

("ask  259. — D.  April  2,1910.  Mr.  H.,  male.  Twenty  years' 
history,  much  worse  last  two  years,  with  vomiting  which  is 
copious  and  foul. 

Operation: '  Duodenum  one  inch  beyond  pylorus  contracted 
to  thickness  of  a  lead-pencil.  Stomach  enormously  dilated 
and  hypertrophied.  Posterior  gastro-enterostomy.  Recovery. 
Sent  by  Dr.  Holderness,  Huddersfield. 


Detailed  Statement  of  Cases  Operated  Upon  45 1 

Report  May,  1911:  Present  condition  very  good.  Has 
gained  4V4  stone  in  weight. 

Case  260. — D.  April  4,  1910.  S.  B.,  male,  aged  forty. 
Typical  history  for  a  number  of  years;  four  months  ago 
melama.    Attacks  worse  during  winter. 

Operation:  Ulcer  just  beyond  pylorus.  Adhesions  to  liver 
and  gall-bladder.  Posterior  gastroenterostomy.  Infolding. 
Recovery.     Sent  by  Dr.  Pickles,  Leeds. 

Report  May,  1911:  "I  am  quite  well  and  a  lot  stronger, 
only  I  have  pains  now  and  again  from  wind." 

Case  261. — D.  April  8,  1910.  I.  W.,  male,  aged  forty- 
five.  Twelve  years'  history.  Occasional  vomiting.  Xo 
h  rmatemesis  nor  melaena. 

Operation:  Small  duodenal  ulcer.  Posterior  gastro-enter- 
ostomy.  Infolding.  Recovery.  Sent  by  Dr.  Edmondson, 
Lancaster. 

Report:  Xot  obtainable. 

Case  262. — D.  April  8,  1910.  H.  M.,  male,  aged  twenty- 
two.  Very  severe  attack  of  pain  six  years  ago,  was  confined 
to  bed  two  weeks.  Since  then  periodic  attacks  of  pain, 
frequent  vomiting.     No  haematemesis  nor  melaena. 

Operation:  An  ulcer  one  inch  beyond  pylorus,  about  the 
size  of  a  shilling.  Duodenum  and  omentum  firmly  adherent 
to  liver  (subacute  perforation).  Posterior  gastroenterostomy. 
Infolding.     Adhesions  not  disturbed.     Recovery. 

Report  August,  1911:  "I  have  been  remarkably  will 
since  you  operated  upon  me  in  April,  1910." 

(  \se  263. — D.  May  3,  1910.  M.  D.,  female,  aged  thirty- 
five.  Indigestion  all  her  life.  Haematemesis  and  melaena 
on  four  occasions. 

Operation:  Small  ulcer  just  beyond  pylorus.  Appendix 
small  and  shrivelled.  Posterior  gastroenterostomy.  Infolding. 
Appendicectomy.     Recovery.    Sent  by  Dr.  Farrer,  Brighouse. 

Report   May,  1911:    Is  enjoying  good  health.    Has  received 

greal    benefit. 

Case  204.  G.  &  D.  May,  1910.  F.  VY..  female,  aged 
fifty-eight.  Six  months'  history  <>f  almosl  constant  pain, 
frequent  vomiting.  Pain  not  relieved  by  food.  No  history  of 
haematemesis  nor  melaena. 


452  Duodenal  Ulcer 

Operation:  A  large  ulcer  on  lesser  curvature  adherent  to 
an  invading  liver.  Second  smaller  ulcer  in  duodenum.  Ante- 
rior gastroenterostomy  on  cardiac  side  of  ulcer;  afferent  limb 
divided,  lower  end  closed,  and  upper  implanted  into  side  of 
efferent  limb  (modified  Roux's  operation).     Recovery. 

Report  May,  191 1:  "I  am  pleased  to  say  I  have  recovered 
remarkably  well  and  am  able  to  get  about  my  work  wonder- 
fully." 

Case  265. — G.  &  D.  May  6, 1910.  S.  L.,  male,  aged  forty- 
six.  Two  years'  history.  Pain  at  first  two  to  three  hours 
after  food;  recently  much  earlier.  Vomiting.  During  last 
month  hsematemesis  and  melsena. 

Operation:  Large  ulcer  involving  pylorus  and  spreading 
into  duodenum  and  lesser  curvature  of  stomach.  Posterior 
gastro-enterostomy.     Recovery. 

Report  May,  191 1:  Gained  4  stone.  A  different  man 
altogether.      Eats  anything. 

Case  266. — G.  &  D.  May  16,  1910.  F.  R.,  female,  aged 
twenty-nine.  Trouble  commenced  thirteen  years  ago.  Very 
severe  pain  and  frequent  vomiting;  hsematemesis  five  years 
ago.  Has  been  in-patient  in  medical  side  of  the  Infirmary 
with  only  temporary  relief. 

Operation:  Ulcer  the  size  of  sixpence  in  first  part  of  duo- 
denum, another  small  ulcer  on  posterior  aspect  of  lesser  cur- 
vature of  stomach.  Posterior  gastro-enterostomy.  Infolding. 
Recovery. 

Report  May,  191 1:  "I  am  pleased  to  say  I  feel  better. 
Occasional  sickness  now  and  then,  but  I  think  as  I  get  stronger 
it  will  go  off.     I  am  very  satisfied. 

Case  267. — D.  May  17,  1910.  Mr.  G.  Twenty-five 
years'  history  of  typical  attacks  of  pain.  No  melsena  nor 
hsematemesis.  Worry  and  hard  work  always  liable  to  bring 
on  attack. 

Operation:  A  hard  indurated  ulcer  one  inch  beyond  pylorus, 
duodenum  tightly  tucked  back  beneath  liver.  Stomach  small. 
Posterior  gastro-eni urostomy.  Infolding.  Recovery.  Sent  by 
Dr.  Hertz,  London. 

Report  from  Dr.  Hertz:  Present  condition  inclined  to  be 
constipated,  has   to   be  careful   with   diet, — e.  g.,  eggs  cause 


Detailed  Statement  of  Cases  Operated  Upon  455 

sickly  feeling, — but  quite  free  from  old  ulcer  symptoms.     "I 
feel  very  fit,  indeed,  life  feels  worth  living." 

Case  268. — D.  May  19,  1910.  Mr.  W.,  aged  forty-six. 
For  last  twenty-five  years  attacks  of  pain  in  left  side  of 
abdomen;  latterly  these  are  more  frequent  and  worse,  pain 
colicky  in  type,  no  vomiting,  often  has  to  have  morphia. 
Recently  pain  and  discomfort  two  hours  after  food;  consider- 
able eructation  of  gas.  A  lump  the  size  of  an  orange  can  be 
palpated  a  little  below  and  to  left  of  umbilicus. 

Operation:  The  tumour  was  a  mass  of  calcareous  tubercu- 
lous mesenteric  glands;  all  mesenteric  glands  enlarged  and 
hard.  Appendix  was  contracted  and  scarred  at  its  base,  and 
lay  in  a  pocket  of  adhesions  behind  caecum.  Marked  ulcera- 
tion in  duodenum  half  an  inch  beyond  pylorus;  a  hard  mass 
with  much  puckering  and  scarring;  stomach  a  little  dilated. 
Posterior  gastroenterostomy.  Infolding.'  Appendicectomy. 
Recovery.     Sent  by  Dr.  Sutcliffe. 

Report  August,  191 1:  In  very  good  health.  No  recur- 
rence of  pain  nor  vomiting. 

Case  269. — D.  May  21,  1910.  C.  B.,  male,  aged  forty- 
nine.  Twenty  years'  history.  During  last  two  years  attacks 
more  frequent  and  severe.  Copious  vomiting.  No  hsemat- 
emesis  nor  melaena.    Lost  2  stone  in  weight. 

Operation:  Large  cicatrising  ulcer  in  duodenum,  adherent 
to  gall-bladder  and  liver.  Many  adhesions  between  jeju- 
num and  omentum.  Posterior  gastroenterostomy  (Mayn's 
method).     Infolding.     Recovery. 

Report  May,  1911:  Well  nourished  and  much  stouter. 
Gained  2  stone.  No  recurrence  of  pain  nor  vomiting.  Con- 
siders operation  has  been  a  complete  success. 

Case  270. — G.  &  I).     May  26,  1910.    I.  M.,  female, 
thirty-two.     Pain  immediately  after  food  began  twelve  years 
ago;  relieved  by  vomiting;  once  haematemesis.     Long  interval 
of  freedom  from  pain,  and  then  recurrence  two  years  ago. 

Operation:  Small  ulcer  in  first  pari  of  duodenum ;  two  small 
ulcers  close  together  on  anterior  wall  of  stomach.  Posterior 
gastro-enterostomy.  Infolding.  Excision  of  gastrii  ulcers. 
Recovery.     Sen1  by  Dr.  Wilson,  Oldham. 

Report  September,  [911:    Her  condition  greatly  improved. 


454  Duodenal  Ulcer 

Increased  4  lbs.  in  weight  since  operation — remains  station- 
ary. No  pain  at  any  time.  Functions  of  stomach  and  bowels 
normal  without  medical  treatment.  Still  neurasthenic.  Can 
eat  anything,  in  contrast  to  milk  diet  (even  then  with  vomit- 
ing) for  three  years  previous  to  operation. 

Case  271. — D.  May  30,  1910.  Mr.  J.,  aged  forty-four. 
Twenty  years'   typical   history. 

Operation:  Small  indurated  ulcer  on  posterior  wall  of 
duodenum  at  lower  margin;  a  pale  area  on  anterior  wall 
opposite — possibly  another  early  ulcer.  Appendix  kinked  by 
adhesion.  Posterior  gastroenterostomy.  Infolding.  Appen- 
dicectomy.  Recovery.  Sent  by  Dr.  Crawford  Watson,  Har- 
rogate. 

Report:  Seen  in  July,  191 1.  Very  well,  indeed,  in  all 
particulars. 

Case  272. — D.  June  1,  1910.  L.  T.  S.,  male,  aged  forty- 
five.  Six  years  ago  commenced  to  suffer  from  attacks  of  pain 
two  to  two  and  one-half  hours  after  meals,  relieved  by  food. 
Last  three  years  pain  has  commenced  soon  after  a  meal  and 
is  not  relieved  by  food. 

Operation:  An  indurated  ulcer  on  anterior  aspect  of  first 
part  of  duodenum.  Small  hard  nodules  of  growth  in  liver  and 
gall-bladder;  a  large  nodule  in  falciform  ligament  was  excised 
for  examination.  Posterior  gastroenterostomy.  Sent  by 
Dr.  Maffin,  Almondbury. 

Pathological  report:  The  mass  is  extensively  invaded 
by  adeno-carcinoma.  Patient  recovered  frorh  operation,  but 
died  deeply  jaundiced  in  August,  1910.  No  post-mortem 
was  performed,  and  the  primary  seat  of  malignant  disease 
not  demonstrated. 

Case  273. — D.  June  4,  1910.  W.  F.,  male,  aged  forty- 
five.  Quite  well  until  eight  years  ago.  For  seven  years 
onwards  from  this  suffered  from  attacks  of  pain  in  abdomen, 
across  upper  part  chiefly;  attacks  lasted  one  week  and  were 
separated  by  intervals  of  three  months.  Pain  comes  some- 
times, not  always,  one  to  one  and  one-half  hours  after  food, 
and  is  accompanied  or  followed  by  vomiting.  No  seasonal 
variation;  attacks  begin  and  end  abruptly.  Never  haematem- 
esis  or  melaena.    Knee-jerks  absent.    No  pupil  reaction;  pupils 


Detailed  Statement  of  Cases  Operated  Upon  455 

small  and  unequal.  X-ray  shewed  small  active  stomach. 
Gastric  stasis  of  moderate  degree;  some  hypertrophy  of 
stomach.  Test-meals:  after  ordinary  meal,  abundant  food 
residues,  yeast,  sarcina?.  no  blood,  slight  HO,  cocci.  Sent 
by   Dr.    Drury,   Southport. 

Operation:  Appendix  tortuous,  engorged,  full  of  concretions — 
removed.  Duodenum  almost  surrounded,  about  1  inch  from 
the  pylorus,  by  the  pancreas,  which  was  closely  adherent  on 
anterior  surface  in  lower  half.  Here  there  was  some  indura- 
tion; on  separating  off  pancreas  a  small  opening  made  into 
duodenum.  Definite  constriction  produced  by  pancreas  and 
ulcer  (as  it  seemed  to  be).  Posterior  gastroenterostomy. 
Stomach  very  shallow,  indeed. 

Pathological  report  on  appendix:  The  mucosa  and  sub- 
mucosa  are  much  swollen  and  infiltrated  by  round  cells. 

Report  May,  1911:  Dr.  Drury  writes:  "Is  acting  as 
gate-keeper  at  level  crossing  on  Midland  Railway  in  South 
Wales.  He  looks  well,  but  is  a  trifle  shaky  on  his  legs,  and  was 
not  in  a  condition  to  return  to  his  own  employment  as  a 
Goods  Guard.  He  has  regained  his  normal  weight.  A  few 
weeks  after  coming  home  he  was  taken  with  pain  and  vomit- 
ing; in  a  few  days  he  was  better  and  went  to  the  Convalescent 
Home  at  Heme  Bay.  Was  taken  ill  there  with  pain  and  vomit- 
ing, and  was  sent  to  Guy's  Hospital.  Vomit  was  dark  and 
greenish  looking,  smelling  strongly  of  bile.  Has  diplopia  to 
a  slight  extent,  is  unsteady  in  his  walk,  gets  periodical  attacks 
of  pain  and  sickness,  and  was  treated  at  Guy's  Hospital  by 
Dr.  Hertz  for  tabes.  He  has  not  been  under  my  care  for  some 
time,  having  been  in  Guy's  Hospital  for  a  couple  of  months 
and  afterwards  at  the  Union  Hospital,  Stockport.  He  was 
treated  for  tabes  at  Guy's  with  potassium  iodide  and  mercury, 
and  did  very  well.  On  returning  home  was  again  seized  with 
pains  and  vomiting  and  went  to  hospital  in  Stockport;  was 
discharged  from  there,  and  I  gol  him  lighl  work  in  South 
Wales.  I  have  not  seen  him  for  a  month,  but  am  given  t<> 
understand  he  is  going  along  prel  ty  well.  The  man  is  undoubt- 
edly suffering  from  tabes. 

Case  274.  I).  June  9,  [910.  Dr.  C.  Always  weak 
stomach,  and  more  easily  upsel   than  others.     In    [899  had 


456  Duodenal  Ulcer 

acute  diarrhoea  and  vomiting  going  through  an  alkali  country, 
since  then  never  quite  right. 

Operation:  Duodenum  much  scarred  by  ulceration  and 
adherent  to  liver,  probably  site  of  old  perforation.  Many 
dense  adhesions  of  omentum  to  anterior  abdominal  wall 
along  site  of  old  incision — these  were  divided.  Posterior 
gastroenterostomy.     Infolding.     Recovery. 

Report:  Patient  writes:  "Present  condition  fair.  Have 
worked  steadily  since  returning  home,  October  1,  1910,  with 
the  exception  of  a  short  hunting  trip  which  I  enjoyed  more 
than  any  for  several  years.  Am  very  tired  towards  evening, 
and  have  to  be  very  careful  not  to  overdo.  Am  steadily  gain- 
ing endurance.  Former  weight,  168  lbs.,  now  160.  Have  had 
no  real  pain,  and  only  insignificant  sensations  of  hyperacidity. 
After  a  few  days'  continuous  work  am  apt  to  feel  slight  hyper- 
acidity, sensation  easily  relieved  by  food  and  even  by  a  glass 
of  water.  No  vomiting.  Ever  since  the  operation  my  bowels 
have  been  loose  and  I  have  been  subject  to  violent  attacks  of 
griping  pain,  followed  in  about  an  hour  by  any  enormous  loose 
movement.  These  attacks  occurred  at  first  every  few  days, 
but  now  occur  only  once  a  week.  On  the  whole,  however, 
my  bowels  are  less  troublesome  than  before  the  operation, 
when  I  was  constipated.  I  regard  the  change  from  costive- 
ness  to  looseness  as  being  much  in  my  favour.  I  feel  that 
a  good  vacation  would  probably  make  me  perfectly  well,  and 
I  hope  to  be  able  to  take  one  before  long;  as  it  is,  I  consider 
the  result  of  the  operation  as  very  satisfactory,  and  it  seems  to 
me  that  such  discomfort  as  I  do  have  is  to  be  attributed  to 
the  irritation  of  adhesions  rather  than  to  duodenal  ulcer  or 
gastro-enterostomy.  There  is  a  marked  difference  in  the  char- 
acter of  my  stools.  They  are  greater  in  volume  and  lighter  in 
colour.  The  looseness  is  never  excessive,  and  I  often  have 
only  a  single  movement  in  the  twenty-four  hours.  I  seldom 
have  over  four;  I  am  very  much  benefited,  but  not  well,  hence 
neurasthenic." 

Case  275. — D.  June  14,  1910.  H.  N.,  male,  aged  twenty- 
four.     Ten  months'  history.     Melaena  nine  weeks  ago. 

Operation:  Ulcer  in  first  part  of  duodenum.  Appendix 
thickened  and  slightly  injected,  with  a  few  slight  adhesions. 


Detailed  Statement  of  Cases  Operated  Upon  457 

Posterior  gastroenterostomy.  Infolding.  Appendiceetomy. 
Sent  by  Dr.  Woodcock,  Leeds. 

Report  May,  1911:  "He  was  well  when  I  last  heard.  Is 
in  America." 

Case  276. — D.  June  24,  1910.  C.  S.,  male,  aged  thirty. 
Since  two  years  ago  dull  aching  pain  three  inches  internal  to 
anterior  superior  spine,  in  attacks  lasting  a  week  or  two; 
four  months  ago  a  severe  attack  of  haematemesis  and  melaena. 

Operation:  An  ulcer  on  posterior  wall  of  first  part  of  duo- 
denum. Appendix  adherent.  Posterior  gastroenterostomy. 
Infolding.     Appendiceetomy.     Recovery. 

Report :     None  obtainable. 

Case  277. — D.  July  9,  1910.  Rev.  W.  F.,  male.  In  July, 
1908,  an  attack  of  acute  gangrenous  appendicitis,  successfully 
operated  on.  Since  that  time  attacks  of  pain  two  hours  after 
food,  relieved  by  food.  Von  Leube's  treatment  has  been 
used  with  temporary  benefit.     Recently  pain  has  returned. 

Operation:  Many  omental  adhesions  in  appendix  area, 
separated  and  tied.  Stomach  hypertrophied  and  dilated. 
In  duodenum,  just  beyond  pylorus,  and  at  extreme  upper 
edge,  an  indurated  white  area  with  firm  band  running  from 
it  to  liver.  Excision  of  ulcer  was  not  possible.  Many  adhe- 
sions in  lesser  sac.  Posterior  gastroenterostomy.  Recovery. 
Sent  by  Drs.  Hartley  and  Lockwood  of  New  York  and  Dr. 
Martin,  Portrush. 

Report  July,  1911:  "Very  well.  A  little  trouble  from 
flatulence  occasionally." 

Case  278.— D.  July  19,  1910.  J.  S.,  male,  aged  forty- 
eight.  Six  years'  history.  Three  months  ago  severe  haemat- 
emesis and  melaena. 

Operation:  A  very  large  indurated  ulcer  on  anterior  wall 
of  duodenum.  Posterior  gastroenterostomy.  Infolding. 
Recovery.    Sent  by  Dr.  Potter,  Barnsley. 

Report  May,  191 1:  He  is  in  perfect  health  and  able  to 
do  his  ordinary  work. 

Case  279. — I).  August  1,  1910.  E.  H.,  male,  aged  thirty- 
six.  Fifteen  years'  history.  Attacks  in  spring  and  winter. 
Occasional  vomiting.     Melaena  five  months  ago. 

operation:     Ulcer  in   first    pari   of  duodenum.     Posterior 


45S  Duodenal  Ulcer 

gastro-enterostomy.  Infolding.  Appendicectomy.  Recovery. 
Sent  by  Dr.  Tweedie,  Sutton-in-Ashfield. 

Report  May,  1911:  In  good  health.  Gained  12  lbs.  in 
weight.     A  complete  cure. 

Case  280. — D.  August,  1910.  Mr.  B.,  male,  aged  sixty- 
eight.  For  fifteen  years  attacks  of  melaena,  shivering,  sweating, 
and  pyrexia,  with  frequent  vomiting.  No  acute  attack  of 
abdominal  pain.  Always  very  sallow  complexion,  motions 
often  clay-coloured. 

Operation:  Gall-bladder  white,  thickened,  and  adherent 
to  omentum  (chronic  cholecystitis),  no  calculi.  Scar  of 
duodenal  ulcer  three-quarter  inch  beyond  pylorus.  Appendix 
short  and  thickened.  Drainage  of  gall-bladder.  Duodenal 
ulcer  excised;  wound  closed  transversely  to  lumen.  Appendi- 
cectomy.    Recovery.    Sent  by  Dr.  Molloy,  Blackpool. 

Report  May,  1911:  Perfectly  well  except  for  occasional 
flatulence. 

Case  281. — D.  August  22,  1910.  Dr.  M.,  male.  Eight 
years'  typical  history.     No  vomiting. 

Operation:  An  indurated  ulcer  three-quarter  inch  beyond 
pylorus.  Posterior  gastro-enterostomy.  Infolding.  Ap- 
|k  ndicectomy.      Recovery. 

Report  June,  191 1:  "In  every  way  as  well  as  could  be 
wished." 

Case  282. — D.  August  26,  1910.  T.  E.  M.,  male,  aged 
twenty-nine.     Eight  years'  history.     No  vomiting. 

Operation:  Small  ulcer  in  first  part  of  duodenum.  Appen- 
dix normal.  Posterior  gastro-enterostomy.  Appendicectomy. 
Recovery.     Sent  by  Dr.  Williams,  Holmfirth. 

Report  May,  191 1:  Occasionally  a  little  pain  just  before 
meals;  sometimes  sour  eructations,  but  these  are  getting  less 
frequent.    Whole  condition  is  one  of  very  great  improvement. 

Case  283. — D.  August  26,  1910.  E.  E.  V.,  male,  aged 
forty-five.  Nineteen  years'  history;  first  symptom  a  haemat- 
emesis. 

Operation:  Large  ulcer  in  first  part  of  duodenum.  Appen- 
dix full  of  concretions  and  adherent.  Posterior  gastro-enter- 
ostomy. Infolding.  Appendicectomy.  Recovery.  Sent  by 
Dr.  Andrews,  Burmantofts. 


Detailed  Statement  of  Cases  Operated  Upon  459 

Report  August,   191 1:     "Perfectly  well." 

Ca^e  284. — D.  September  2,  1910.  Mr.  D.,  male.  Twenty 
years'  history.  Occasional  vomiting.  Xo  haematemesis  nor 
mela-na. 

Operation:  Well-marked  duodenal  ulcer  with  hard  base; 
marked  stenosis.  Appendix  short  and  buried  in  adherent 
omentum,  large  concretion.  Posterior  gastro-enterostomy. 
Infolding.  Appendicectomy.  Recovery.  Sent  by  Dr. 
Pringle,  Manchester. 

Report  June,  1911:     "Very  well,  indeed." 

Case  285.— G.  &D.  September,  1910.  Mr.  T.,  male,  aged 
fifty-four.  Twenty  years'  history.  Much  worse  last  three 
years.  Pain  two  hours  after  food.  Occasional  vomiting. 
Haematemesis  five  months  ago.     Lost  2  stone  in  weight. 

Operation:  Two  ulcers  in  first  part  of  duodenum.  Extend- 
ing from  pylorus  along  lesser  curvature  of  the  stomach  a 
large  ulcer;  this  was  very  hard  and  highly  suggestive  of  car- 
cinoma. Partial  gastrectomy,  lesser  curvature  divided 
close  up  to  cardia.  Posterior  gastro-enterostomy.  Duo- 
denum closed.     Recovery.     Sent  by  Dr.  Webster,  Golcar. 

Report  May,  1911:  Gained  2  stone  in  weight.  Is  now  in 
good  health  and  attending  to  his  work  regularly. 

Case  286. — D.  September  16,  1910.  H.  S.,  male,  aged 
forty-three.     Nine  years'  history.     No  vomiting,  no  melaena. 

Operation:  Small  triradiate  duodenal  ulcer.  Posterior 
gastro-enterostomy.  Infolding.  Appendicectomy.  Recovery. 
Sent  by  Dr.  Ellis,  Halifax. 

Report  July,  191 1:  Gastric  condition  quite  satisfactory, 
occasional  attacks  of  palpitation. 

Case  287. — D.  September  16,  1910.  E.  M..  male,  aged 
forty-three.  Fourteen  years'  history.  Two  attacks  of  haemat- 
emesis and  melaena. 

Operation:  Ulceration  in  firsl  part  of  duodenum,  with 
stenosis  and  pouching.  Appendix  long  and  thin.  Posterior 
gastro-enterostomy.    Infolding.    Appendicectomy.    Recovery. 

Report  :      None  obtainable. 

Case  288. — D.  September  [6,  [910.  F.  II..  female,  aged 
twenty-two.  Forthree  years  attacks  of  pain  after  food,  often 
accompanied  by  vomiting.    Slight  melaena  on  several  occasions. 


460  Duodenal  Ulcer 

Operation:  A  small  duodenal  ulcer  just  beyond  pylorus. 
No  gastric  ulcer.  Appendix  long,  its  end  adherent,  contained 
,i  concretion.  Posterior  gastro-enterostomy.  Infolding.  Ap- 
pendicectomy.    Recovery.    Sent  by  Dr.  Brook,  Lincoln. 

Report  May,  191 1:  Is  "up  and  down,"  occasional  attacks 
of  pain  and  sickness;  but  can  do  her  work  as  housemaid,  and 
is  decidedly  much  better  since  the  operation.  No  appreciable 
difference  in  weight —  8  stone  9^  lbs.  Has  pain  of  a  burning 
character  two  or  three  times  a  week  at  the  site  of  the  abdomi- 
nal wound,  generally  at  11  a.  M.,  but  this  has  occurred  some- 
times at  10  p.  M.  Vomited  about  twice  a  week  latterly. 
Character  of  vomit  very  bitter;  comes  on  with  an  attack  of 
pain,  and  the  vomiting  gives  relief  to  the  pain.  These  attacks 
of  pain  and  sickness  are  very  slight  compared  to  what  they 
were  before  the  operation,  and  between  the  attacks  the 
patient  feels  quite  well. 

Case  289. — D.  September  16,  1910.  A.  G.,  male,  aged 
ihirty-five.  Eighteen  years'  history.  No  haematemesis  nor 
melaena. 

Operation:  Multiple  ulcers  in  first  part  duodenum  with 
pouching.  Appendix  normal.  Posterior  gastro-enterostomy. 
Appendicectomy.    Recovery.    Sent  by  Dr.  Molloy,  Blackpool. 

Report  May,  191 1 :    Perfectly  well. 

Case  290. — D.  October  7,  1910.  Mr.  De  L.  Five  years' 
bad  indigestion  and  pain,  stomach  troubles  for  ten  years. 
Pain  with  quite  free  intervals,  no  fixed  hours,  meals  not  very 
regular.  If  pain  is  on  and  food  taken,  pain  relieved.  At 
times  very  severe  agony.  Extreme  heat  or  cold  makes  him 
worse. 

Operation:  An  old  perforation  of  a  duodenal  ulcer  adherent 
to  liver.  Posterior  gastro-enterostomy.  Appendicectomy. 
Recovery. 

Report  April,  191 1:  "I  am  in  good  health  and  have  no 
trouble  of  any  kind." 

(  ase  291. — D.  October  8,  1910.  Dr.  J.,  male,  aged  forty- 
tour.  Eight  years'  history.  Never  vomited.  No  melaena. 
\\  as  eight  weeks  in  bed  with  oil  treatment,  only  temporary 
relief. 

Operation:     A  thick,  very  hard  duodenal  ulcer.     Appendix 


Detailed  Statement  of  Cases  Operated  Upon  461 

chronically  inflamed  and  adherent.  Posterior  gastroenter- 
ostomy.    Infolding.     Appendicectomy.     Recovery. 

Report,  May,  1911:  "I  can  eat  well  and  sleep  well;  the 
operation  has  made  a  new  man  of  me." 

Case  292. — D.  Carcinoma  ventriculi.  October  24,  1910. 
Mrs.  W.,  aged  fifty.  All  her  life  she  has  had  indigestion,  pain 
after  food,  with  occasional  attacks  of  vomiting.  She  has 
remained  at  one  weight  until  the  last  twelve  months,  when 
she  began  to  waste.  The  pain,  as  a  rule,  comes  on  some  hours 
after  food,  was  always  on  the  left  side  and  high  up  in  the 
abdomen,  under  the  left  costal  margin;  more  food  always 
relieved  it  for  a  few  hours,  and  she  habitually  took  hot  water 
and  milk  for  this  purpose.  She  was  frequently  waked  up  at 
night  by  pain  and  took  hot  water  for  ijt.  She  was  always 
worse  in  winter.  During  the  last  twelve  months  the  pain  has 
been  almost  constant,  vomiting  and  retching  frequently,  and 
sleepless  nights  the  rule.  She  thinks  now  that  food  does  not 
relieve  her,  and  she  is  constantly  bringing  up  mouthfuls  of 
"acid"  fluid  and  gas,  but  never  any  blood.  She  has  lost  all 
appetite,  and  has  now  a  positive  loathing  for  all  foods. 

Operation:  There  was  a  malignant  mass  on  greater  cur- 
vature, two  inches  from  pylorus.  There  were  masses  of  glands 
enlarged  all  along  the  lesser  curvature  and  half  way  on  greater. 
There  were  scars  of  old  ulcers  at  pylorus  and  in  duodenum. 
Partial  gastrectomy  performed  in  usual  way,  the  duodenum 
being  divided  one  inch  beyond  the  pylorus  and  five-sixths  of 
the  stomach  being  removed.  Posterior  gastroenterostomy. 
Recovery.     Sent   by  Dr.  Aitchison,  Blackburn. 

Report:  Has  not  been  so  well  for  many  years.  Gain  in 
weight.     No  recurrence  of  pain. 

Case  293.  G.  &  I).  October  27.  1910.  Mrs.  C,  female. 
Five  years'  history  of  slight  indigestion;  twelve  months  ago 
mucous  colitis;  during  lasl  six  months  severe  epigastric  pain, 
almost  constant;  rigors  and  loss  of  weight.  Rarely  vomits; 
no  haematemesis. 

Operation:  Gall-bladder  small  and  white.  No  calculi. 
Manx  adhesions  to  duodenum;  these  were  divided.  Marked 
scar  of  duodenal  ulcer,  which  was  apparently  free  from  activity. 
On  lesser  curvature,  in  contact  with  cardia,  a  huge  crateriform 


462  Duodenal  Ulcer 

ulcer,  adherent  to  pancreas,  obliterating  lesser  sac,  and 
causing  well-marked  hour-glass  contraction.  Appendix  much 
enlarged,  thickened,  and  adherent.  Gastro-gastrostomy. 
Appendicectomy.     Recovery.     Sent  by  Dr.  Wilson,  Harrogate. 

Report  June,  191 1:  Is  taking  ordinary  food  in  good 
quantities  and  has  gained  weight. 

Case  294. — D.  October  28,  1910.  W.  C.  L.,  male,  aged 
thirty-five.  Four  years'  history  and  two  attacks  of  hsemat- 
emesis,  one  a  week  before  operation. 

Operation:  Duodenal  ulcer  on  anterior  wall,  just  beyond 
pylorus.  Posterior  gastro-enterostomy.  Infolding.  Re- 
covery.    Transferred  from  care  of  Dr.  Griffith. 

Report  May,  191 1:  "I  am  much  better  since  my  opera- 
tion.    I  feel  another  person  to  what  I  did  before." 

(  !ase  295. — D.  November  3,  1910.  Mr.  L.  Twenty- 
five  to  thirty  years'  history.  Recently  vomiting  of  large 
quantities.     Marked  gastric  dilatation. 

Operation:  Dense  indurated  ulcer  with  omental  adhesions 
producing  marked  stenosis.  Great  gastric  dilatation.  Pos- 
terior gastro-enterostomy.  Infolding.  Recovery.  Sent  by 
Dr.  Ward  Smith,  Shipley. 

Report  June,  191 1:     Is  very  well. 

Case  296. — D.  November  14,  1910.  J.  E.,  male,  aged 
fifty-eight.  Twenty-eight  years'  history.  Occasional  vomit- 
ing. 

Operation:  Hard  ulcer  in  first  part  of  duodenum,  causing 
pouching.  Appendix  bulbous  and  containing  concretions. 
Posterior  gastro-enterostomy.  Infolding.  Appendicectomy. 
Recovery.     Sent  by  Dr.  Swindale,  Clitheroe. 

Report  May,  191 1:  Feels  stronger  and  better  than  he  has 
done  for  years. 

Case  297. — D.  November  25,  1910.  M.  E.  H.,  female, 
aged  forty-six.  Five  years'  history.  Some  vomiting.  No 
haematemesis  nor  melaena. 

Operation:  A  large  hard  ulcer  on  anterior  surface  of  duo- 
denum;  marked  pouching.  Appendix  long  and  thickened. 
Large  number  of  small  calculi  in  gall-bladder.  Posterior 
gastro-enterostomy.  Infolding.  Appendicectomy.  Chole- 
cystotomy.     Recovery.    Sent  by  Dr.  Howell,  Barnsley. 


Detailed  Statement  of  Cases  Operated  Upon  463 

Report  May,  1911:  Present  condition  good.  Occasionally 
slight  abdominal  pain.     Patient  is  greatly  improved. 

Case  298/ — D.  November  30,  1910.  Mrs.  S.,  female. 
Indigestion  all  her  life.  Typical  symptoms  last  few  years.  Xo 
vomiting,  no  melaena. 

Operation:  Ulcer  one-half  inch  beyond  pylorus,  causing 
considerable  puckering.  Slight  gastric  dilatation.  Appendix 
small,  fibrous,  and  adherent.  Posterior  gastroenterostomy. 
Appendicectomy..  Recovery.  Sent  by  Dr.  Edgecombe,  Har- 
rogate. 

Report:  This  patient  returned  with  a  jejunal  ulcer  in 
191 1.  The  following  is  a  copy  of  her  notes:  Operation  for 
marked  duodenal  ulcer  and  chronic  appendicitis  November 
30,  1 910.  For  a  time  she  had  relief,  but' soon  her  symptoms 
began  again  as  bad  as  ever  and  of  the  same  type,  but  lower 
down  in  the  abdomen,  referred  to  the  umbilicus.  Pain  one 
or  two  hours  after  food,  and  relieved  by  food;  occasionally, 
pain  to  the  right  of  the  middle  line.  Operation  May  15,  191 1 : 
Incision  through  old  scar.  There  were  many  adhesions  all 
over.  At  the  lowest  part  of  the  anastomosis  was  a  hard,  white, 
indurated  mass,  involving  the  transverse  colon,  with  a  crater 
on  it  which  felt  through  anterior  wall  of  stomach  about  one 
inch  long  and  one-half  inch  to  three-quarter  inch  broad,  the 
whole  being  plastered  down  by  adhesions.  After  separation 
the  crater's  base  was  formed  by  transverse  colon  and  transverse 
mesocolon,  and  the  edges  were  in  the  line  of  the  lowest 
point  of  the  anastomosis  between  the  stomach  and  the 
jejunum,  involving  both  organs.  The  whole  area  was  cul 
away,  the  transverse  colon  lifted  up,  and  its  crater  covered 
in  by  omentum.  The  gap  in  the  anastomosis  line  was 
stitched  up  by  a  row  of  interrupted  catgui  stitches  and  "in- 
continuous  Pagenstecher.  A  wide  opening  free  from  indura- 
tion was  1<H,  admitting  two  fingers  easily. 

CASE    299.      D.      December   1,    1910.     Col.  P.,  male.      Eight 

years'  history.     No  vomiting;  no  melaena. 

Operation:     Well-marked    ulcer    beginning    to   cause   con 
traction.       Posterior     gastro-enterostomy.       Infolding.      Re- 
covery. 

Report  May,  [911:     "A  perfecl   result." 


464  Duodenal  Ulcer 

Case  300. — D.  December  2,  191  o.  J.  J.  B.,  male,  aged 
twenty-one.     Two  years'  history.     No  vomiting;  no  melacna. 

Operation:  Small  white  puckered  scar  just  beyond  pylorus. 
Appendix  adherent.  Posterior  gastro-enterostomy.  Infolding. 
Appendicectomy.     Recovery. 

Report  May,   1911:    Very  well,  indeed. 

Case  301. — D.  December  7,  1910.  Mr.  J.,  male.  Twenty 
years'  indigestion;  recently  pain  much  earlier  after  food.  A 
number  of  attacks  of  pain  of  great  severity  recently,  followed 
by  jaundice. 

Operation:  Marked  duodenal  ulcer  in  mass  of  induration 
one  inch  beyond  pylorus.  A  number  of  calculi  in  a  small 
hard  gall-bladder.  Posterior  gastro-enterostomy.  Infolding. 
Cholecystectomy.  Recovery.  Sent  by  Dr.  Andrew's,  Bur- 
man  tofts. 

Report  August,  1911:    Perfectly  wrell. 

Case  302. — D.  December  7,  1910.  J.  H.,  male,  aged 
fifty-two.  Four  years'  history.  Haematemesis.  Gastric 
lavage  during  last  three  months. 

Operation:  Stomach  considerably  dilated.  Large  duodenal 
ulcer  producing  stenosis.  Posterior  gastro-enterostomy. 
Infolding.     Recovery.     Sent  by  Dr.  West. 

Report  May,  1911:  In  excellent  health.  Can  eat  any- 
thing without  discomfort.     Gained  27  lbs.  in  weight. 

Case  303. — D.  December  8,  1910.  Mrs.  M.,  female,  aged 
twenty-seven.  Vague  abdominal  pains  since  age  of  twelve. 
Last  eighteen  months  severe  attacks  of  pain  at  varying  intervals 
.titer  food,  temporarily  relieved  by  rest  in  bed  and  fluid  diet. 
For   last   year   gastric   lavage. 

Operation:  Indurated  ulcer  in  first  part  of  duodenum  with 
marked  pouching.  Stomach  large  and  hypertrophied.  Ap- 
pendix contained  a  concretion,  but  was  not  adherent.  Pos- 
terior gastro-enterostomy.  Infolding.  Appendicectomy.  Re- 
covery.     Sent  by  Dr.  Craven  Moore,  Manchester. 

Report  May,  1911:  Strong  and  healthy.  Gained  over  1 
stone  in  weight.     No  recurrence  of  pain. 

i  304. — D.  December  18,  1910.  Mr.  B.I.,  male,  aged 
fifty-five.  Attacks  of  abdominal  pain  since  boyhood.  An 
acute  illness  when  at  college,  probably  appendicitis.    Typical 


Detailed  Statement  of  Cases  Operated  Upon  465 

attacks  of  pain  for  last  two  years;  nine  months  ago  hsematem- 
esis.     Has  been  on  olive-oil  treatment  without  benefit. 

Operation:  Indurated  area  in  first  part  of  duodenum  with 
adhesions  to  liver.  Appendix  thin,  end  bulbous,  completely 
buried  in  parietal  peritoneum.  Posterior  gastroenterostomy. 
Infolding.  Appendicectomy.  Recovery.  Sent  by  Dr.  Cath- 
cart   Bruce,   London. 

Report  May,  1911:    Perfectly  well. 

Case  305. — D.  December  20,  1910.  A.  C,  female,  aged 
fifty-five.  Eighteen  months'  history  of  severe  pain  two  to 
three  hours  after  food,  with  vomiting.  Has  been  for  months 
on  slop  diet  and  has  had  lavage.  Has  lost  3  stone  in  weight, 
and  recently  has  been  rapidly  losing  strength,  until  now  she 
is  very  wasted,  cachectic,  and  anaemic.  Forra  number  of  days 
previous  to  operation  continuous  proctoclysis  was  undertaken, 
in  order  to  improve  her  condition. 

Operation:  An  indurated  duodenal  ulcer  adherent  to  pan- 
creas. Posterior  gastroenterostomy.  Infolding.  Appen- 
dicectomy. Sent  by  Dr.  Robinson,  Masham.  Patient 
rallied  well  from  the  operation.  On  January  2,  191 1  (thirteen 
days  after  operation),  whilst  the  nurse  was  washing  her,  she 
complained  of  feeling  faint  and  collapsed,  dying  in  a  few- 
minutes. 

Postmortem  findings:  A  chronic  duodenal  ulcer  with  in- 
durated margins  and  floor  formed  by  the  pancreas;  caseous 
tuberculosis  of  retroperitoneal  glands.  Operation  area  and 
rest  of  abdomen  normal.  Renal  capsules  slightly  adherent. 
Myocardium  fibrous.  Right  pleural  sac  obliterated  by 
adhesions.  Death  apparently  resulted  from  sudden  cardiac 
failure. 


30 


INDEX  OF  AUTHORS 


Abercrombie,  19,  20 

Adam,  347 

Adams,  122.  374,  450 

Adriance,  102 

Aitchcson,  423,  461 

Alderton,  363,  366,  379,  41 7 

Alexander,  440,  441 

Allbutt,  297 

Anderson,  403 

Andrews,  395,  441,  458,  464 

Arming,  132,  377,  44.S 

Arnison,  436 

Arriley,  369 

Awburn,  438 


Babington,  56 
Bailey,  335.  33r>.  434 
Baillard,  85 
Bampton,  346 
Barclay,  80,  137 
Bane,  44,  45,  48,  52,  66 
Barnard,  231 
Barrs,  255,  346 
Battle,  200 
Beaman,  402 
Beattie,  443 

ling,  356 
Berg,  251,  252 
281,  382 
Bingham,  212 
Blair,  74-  137 
Blair-Bell,  446 
Blake,  238 
Borland,  101 
Bowman,  36 
Box,  154,  155 
Boxwell,  314 


Braithwaite,  211,  212,  213 

Braun,  196 

Brewer,  91,  93,  94,  350 

Bright,  56,  73,  75 

Broadbent,  361 

Brook,  460 

Broussais,  301 

Brown-Sequard,  36 

Bruce,  465 

Brunton,  362 

Bryant,  60 

Buckley,  404 

Bucquoy,  20,  250 

Budd,  283 

Burgess,  238 

Burnett,  394 


(  airi),  142,  216 
( '.micron,  408 
<  Campbell,  419 
(  annon,   1 1 8 
Carans,  85 
( !arnes,  420 
(  .iinl,  91,  93 

421,  442 
Carter,  228 
'  'ass,  37<> 
Chadwell,  289 
( !holmeley,  7'' 
( "hrisi  ie-Wilson,  305 
("hurl.. n.  385,  v" 
( Ihvostec,  20 
Clark,  75.  7<s.  79 
Clarke,  239,  356,  435.  4  l' 
(  I.iikIc  44.  H2 

(  lements,  366 
467 


468 


Index  of  Authors 


Cork,  55 

Codivilla,  22 

Codman,  23.  312 

Collin,  21,  264 

Collinson,  317 

Corry,  398 

Court,  387 

Cowan,  408 

Crawford,  362 

Crile,  91 

Crowley,  403 

(rump,  350,  359 

Curling,  24,  25.  26,  34,  35,  36 


Dai.che,  44 
Danid,  445 
Davidson,  388 
Dawson,  427 
Dean,  21,  241 
Dearden,  394,  446 
Delaunay,  45,  47,  66 
Denning,  382 
Dickinson,  45,  52,  287 
Dimmock,  374 
Donkin,  98 
Dowsing,  389,  394 
Drury,  455 

Dunderdale,  285,  422,  423 
Dunn,  21,  241 
Dupuytren,  25 
Durham,  32,  34,  53 


E  \-l  ES,  448 

Edgecombe,  209,  41 1,  463 

Edmondson,  434,  451 

Edwards,  445 

Eichhorst,  315 

Elliott,  446 

Ellis,  312,  338,  339,  353,  368,  400, 

44°,  459 
Elsasser,  81 
Elvins,  446 
Erichsen,  35 
Eve,  161,  231 
Ewald,  315 


Ewart,  49,  64 
Exley.  354 


Fal ken bach,  19 

Falkner,  384 

Farrer,  451 

Fawsitt,  405 

Fearnley,  342 

Fenwick,  37,  125,  155,  284 

Ferguson,  447 

Finney,  194 

Finny,  89,  102,  215 

Fisher,  91,  94 

Fletcher,  61,  445 

Flint,  433 

Foley,  388 

Forster,  55,  248,  283,  310 

Forsyth,  188 

Francine,  83 

Franklin,  239 

French,  297 

Frerichs,  296 

Friend,  401 

Fryer,  403 


Galletly,  441 
Galloway,  375 
Gandy,  37 
Genrich,  85,  97 
Gibson,  122 
Gillibrand,  44S 
Golding-Bird,  307 
Goode,  348,  370,  381 
Goodhart,  314 
Grant,  424 
Griesbach,  351 
Griffith,  159,  450,  462 
Grunfeld,  301,  302 


Habhrshon,  77,  303,  313 
Hacker,  168 

Haigh,  371,  383,  390,  397,  398 
Haldane,  63 

Hall,  197,  435 


Index  of  Authors 


469 


Hamilton,  373 

Handheld-Jones,  36 

Harbinson.  379 

Hardwick,  444 

Harrington,  294 

Harrison,  296 

Harrowell,  440 

Hartley,  457 

Harvey,  402 

Hawkins,  42 

Hawkyard,  351,  384,  437 

Hebb,  63,  80 

Hebblethwaite,  370,  381 

Hecker,  85,  95 

Helmholz,  86,   87,   88,   89,   90,    103, 

106 
Henderson,  434 
Henoch,  85,  100 
Hergott,  85 
Hertz,  44,   114,   i2i,   134,   140,  452, 

455 
Herzfelder,  283 
Hills,  42 
Hinde,  369 
Hinings,  362 
Hochenegg,  181,  184 
Hoffmann,  249,  308 
Hogarth,  356 
1  [olderness,  450 
Holliday,  373 
Holmes,  35,  39 
Horsfall,  407 
I  lousman,  410 
Howell,  402 
Hudson,  263 
Hughes,  76,  77,  445 

Hunter,  36,  37 

[rvine,  19 


Jalland,  370 

Jefferson,  448 
Johnson,  404 
John-ton,  37.S 
Johnstone,  383 
Jordan,  135.  i.V> 


Kammerer,  350 
Keate,  43,  55 
Kelling,  252 
Kelly,  441 
Kendall,  99 
Kennedy,  383 
Kerr,  190,  192 
Key,  197 
Kirke-YYhite.  406 
Kling,  85,  97 
Klinger,  19 
Knaggs,  255 
Knight,  449 
Knowles,  384 
Kocher,  161,  194 
Krause,  20,  23,  125,  24s 
Krauss,  81,  282 
Krehl,  121 
Krug,  84 
Kundrat,  97 
Kuttner,  100,  101 


Lambert,  91,  361,  362,  390,  40* 

Landau,  87,  96 

Lane,  136,  185,  187 

Laplace,  321,  322,  335 

La  Touche,  387 

Laure,  40 

Leatham,  397 

Lecointe,  45 

Lederer,  85 

Lediard,  228 

Lenhartz,  121 

Lennander,  197 

Lespinasse,  91 ,  <)4 

Lesser,  37 

Leube,  120 

Lister,  98 

Liston,  30 

Lockwood,  312,  336,  457 

Long,  27,  30,  31,  308 

Longley,  443 

Low,  389 

Lund,  246,  247 

Luneau,  250 


470 


Index  of  Authors 


M  \i  KENZIE,  277,  278,  283,  341,  355, 
380 

Mai  key,  45 

Maffin,  454 

Malim,  131,  392 

Marchiava,  287 

Marsden,  386 

Marsh,  4115 

Martin,  457 

Man  land,  399,  407 

Mason,  409 

Mathews,  367,  372,  437 

Mathieson,  384 

Mathieu,  44 

Matthews,  252 

Maynard-Smith,  223 

Mayo    (W.  J.),    22,    182,    184,    275, 

278,  311,  321,  453 
McCully,  370 
McGibbon,  387 
McLeod,  382 
McNab,  339.  354.  439 
Meunier,  249,  280,  281 
Miles,  216,  217,  227,  241 
Millard,  281 
Millhouse,  337 
Mitchell,    153,    162,   216,    218,    235, 

240,  241,  279,  372,  388 
Modlin,  437 

Molloy,  401,  426,  458,  460 
Moore,  72,  128,  393,  464 
Morgagni,  271 
Morgan,  287 

Morison,  197,  223,  235,  236 
Moxon,  45,  57,  59 
Muir,  371 
M  tiller ,  121 
Munchmeyer,  98 
Murchison,  69,  75,  79,  80 
Murphy,  1 18,  147,  240,  321,  322 

Nesbitt,  412 

Nicholson,  396 

Noble,  99 

Normington,  35s.  400.  41s,  43c, 

Nothnagel,  125 


(  )'(  lONNEL,  426 

Oldfield,  259,  263,  352,  394 
Oppenheihier,  20,  125,  264 
Oxford,  442 


Packard, 289 

Pagenstecher,  22 

Parker,  190,  192 

Parsons,  380 

Paterson,  122,  153,  154,  196 

Pavy,  76,  313 

Pawlow,  163,  195 

Peck,  316 

Penrose,  46,  64 

Perry,  21,  35,  36,  40,  42,  45,  46,  48, 
5i-  54.  55.  56,  57.  58,  59.  60,  61, 
62,  63,  75,  76,  77,  78,  79,  80,  81, 
125,  249,  264,  271,  283,  301,  306, 
310,  313 

Pickles,  451 

Pilcher,  271,  272,  273 

Pitt,  54 

Ponfick,  35,  37,  40 

Porritt,  97,  199,  340,  361 

Porter,  393 

Potter,  365,  457 

Preston,  364 

Pringle,  459 

Pritchard,  363,  374 

Pye-Smith,  60 


QuENU,  161 

Rayer,  303,  304 

Rees,  54,  57 

Reinhold,  309 

Renon,  44 

Renton,  226 

Rheiner,  99 

Richardson  (Charles),  367,  405 

Richardson  (Maurice),  231,  233 

Riedel,  161 

Riegel,  119,  120,  122 

Rilliet,  85 


Index  of  Authors 


47i 


Robb,  360 

Roberts,  65,  438,  447 
Robinson,  465 
Robson,  341 
Rolf,  353 
Rolleston,  297 
Ross,  367 
Roth,  271 
Roughton,  65,  385 
Roupell,  78 
Roux,  44,  188 
Rowden,  133,  134,  349 
Rowling,  344.  345.  357 
Ryan,  380 


Sadler,  396 

Saintsbury,  65 

Salter.  425 

Sanderson,  309 

Satterthwaite,  82,  83 

Saxer,  99 

Scarborough,  450 

Schmidt,  283,  302,  304,  308,  315 

Sedgwick,  228 

Shann,  434 

Shaw,  21,  35,  36,  40,  42,  45,  46,  48, 
51,  54.  55,  56,  57,  58,  59-  60,  61, 
62,  63.  75,  76,  77.  78.  79.  80,  81, 
125,  249,  264,  271,  283,  301,  306, 

310.  313 
Shive,  369 
Shukowsky,  85 
SilUrmann,  85 
Smith.  435,  444.  450,  462 
Spiegelberg,  85,  95,  96 
Stassano,  54 
Steele,  447 
Stephenson,  406 
Stewart,  112,  128,  309 
Stewart  (Helen  G.),  284 
Stich,  301,  302 
Stokes,  35 
Streeton,  24W 
Sturges,  62,  70,  8< 
Sutcliffe,  453 


Swensson,  286 
Swindale,  399,  412,  462 


Tawse,  413 

Taylor,  343.  395,  411 

Thomas,  435 

Thompson,  364 

Torday,  100 

Tough,  449 

Townsend,  380 

Travers,  17 

Treitz,  45,  51 

Trier,  19,  20,  81,  285 

Trotter,  359,  360,  413,  449 

Turner.  356,  425 

Tweedle,  458 

Tweedy,  417 

Tyrie,  350 


Van  Roojen.  196,  19; 
Yeale,  371,  420 
Veit,  103 
Yon  Hacker,  168 
Von  Krehl,  121 
Yon  Leube,  457 
Von  Muller,  121 


Wadham,  62 
W'ainman,  344,  357 
W'aldeyer,  95,  96 
Wallis,  286 
Ward,  409.  415 
Warfvinge,  304,  305 
Watson,  378,  454 
Watterson,  392 
Waugh,  415 
Webster,  459 
Wedgewood,  43" 
Weir,  21 
Welch,  341 
Wot.  83,  4'. 4 
Whipham,  62, 
White  306 
Whitney,  295 


198,  200 


472 


Index  of  Authors 


Wickham,  443 
Wilkie,  154,  196,  200 
Wilkinson,  396 

Wilks,  35,  45.  58,  59.  76,  7«-  3io 
Willcox,  123 
Williams,  458 
Williamson,  442,  443 
Wilson,  438,  453,  462 
Wood,  402 

Woodcock,  67,  343,  354.  402.  439. 
449.  457 


Woods,  346.  347-  360 
Wright,  410 
Wunderlich,  23 


Yates,  238 

Young,  436 


Zerschwitz, 

Zoia,  283 


NDEX 


Abdomen",  examination  of.  in  chronic 

duodenal  ulcer,  116 
Abdominal    aorta,    involvement    in 
chronic  ulcer,  301,  302 
wall  as  base  of  duodenal  ulcer.  246 
Abscess  between  pancreas  and  duo- 
denum, ulcer  with,  23 
periduodenal,  after  subacute  per- 
foration, 245 
burrowing  of,  248 
in  chronic  perforation,  247,  24CS 
pus  in,  course  of,  249 
rupture  of,  248 
treatment,  251 
Acid  dyspepsia,  ulcer  and,  114,  119- 
124,  129 
gastritis,  duodenal  ulcer  and,  114, 
1 19-124,  129 
Acidity  in  duodenal  ulcer,  114,  119- 

124,  129 
Adhesions,  closure  of  duodenal  per- 
foration by,  244 
in  cholelithiasis,  14K 
in  chronic  ulcer,  267,  268 
to  gall-bladder  in  chronic   ulcer, 
267 
Age,  duodenal  ulcer  and,  107 
Albuminuric  ulcer  of   intestine,    45. 

See  also  Uramic  duodenal  ulcer 
Alimentary     canal     after     bismuth 
ingestion,  .v-ray  findings,  133— 
137 
of  newborn,  haemorrhage  from, 
ulcer  and,  85 
Allis'  forceps  in  gastroenterostomy, 

175 
Ammonium     1  arbonate     e»  rel  ion, 
uraemi*    ulcers  and,   52 


Anaemia,  splenic,  chronic  ulcer  and, 

differentiation,  155,  156 
Analysis  of  cases  operated  upon  in 
1909  and  1910,  428 
to  end  of  1908,  317 
Anastomosis      after      resection      in 
chronic  ulcer,  161,  163 
choledocho-duodenal,     290,     291, 

293 

new  ulcer  after,  196 

part  for,  169 

resection    of,    for    jejunal    ulcer, 
203 
Aneurvsmal    dilatation    in    chronic 

ulcer,  301 
Annular  duodenal  ulcer,  280,  2S1 
Anthrax  of  duodenum,  53,  54 
Antiperistaltic    gastroenterostomy, 

322 
Anus,  uremic  ulcer  of,  44 
Aorta,  involvement  in  chronic  ulcer, 

301,  302 
Appendectomy    with    gastroenter- 
ostomy, 1 84,  201 
Appendicitis,    duodenal    ulcer    and, 
184,  185 
differentiation,  139,   151,   152 

mimicking    duodenal    ulcer,  case, 

153 
perforal  ion  of  duodenal  ulcer  and, 

differentiation,  222,  22~ 
with  duodenal  perforation,  228 
Appendix  dyspepsia,  chronic   ulcer 
and,  differential  ion,  151 
/'/;  situ,  [86 
Appel  ite,  pain  and,  I  I  I 

Arteries,    involvement,   in    chronic 

ulcer,  300 


473 


474 


Index 


BANTl's  disease,  chronic  ulcer  and, 
differentiation,  155,  156 

Basting  stitch  in  gastroenteros- 
tomy, [75 

Belching,  relief  of  pain  by,  110 
Berg's    treatment    of    periduodenal 

abscess,  252 
Bile  change-,  ulcer  from  burns  and, 

36 
Bile-duct,   common,   closure  of,    by 

stenosis,  282,  284 
Bismuth  meals  and  .v-ray  in  chronic 

ulcer,  133,  134 
Bleeder's  disease,  chronic  ulcer  and, 

156 
Blood  changes  after  burns,  37 
transfusion      in      melaena      neo- 
natorum, 91 
Bloodvessels,     involvement     of,    in 

chronic  ulcer,  128,  300 
Blown-out  feeling  in  ulcer,  109 
Boring  pain  in  chronic  ulcer,  no 
Bright's  disease,  ulcer  and,  44 
Bronchitis,      duodenal      perforation 

and,  differentiation,  230 
Burning  pain  in  chronic  ulcer,  no 
Burns,  blood  changes  from,  37 
duodenal  ulcer  from,  24 
age   and,  40 
bile  changes,  36 
cases,  26 
causes,  35,  36 
character,  38 
circular,  40 
deep,  40 
emboli  and,  38 
fistula    into    gall-bladder    in, 

308 
frequency,  31,  38 
haemorrhage  in,  42 
history,  24 
irregular,  40 
multiple,  38 
oval,  40 
perforation,  42,  215 

cases,  28-30 
position,  38 


Burns,    duodenal    ulcer   from,  rela- 
tionship, 35 
septic  emboli  and,  38 
sex  and,  41 
shape,  40 
site,  37 
solitary,  38 
superficial,  40 
surgical  treatment,  42 
•  symptoms,  41 
toluylenediamine     injections 

and,  36 

uraemic,  55 

gastric  ulcer  from,  39 


Canal  of  \\ 'irsung,  involvement  of, 

by  duodenal  ulcer,  286,  299 
Carcinoma  from  chronic  ulcer,  275, 

3ii 
gastric,  hyperchlorhydria  in,   124 
mimicking  duodenal  ulcer,  142, 

143 
gastro-enterostomy  for,  case,  197 
Cardiospasm  in  ulcer,  321 

case,  414,  425 
Cases  operated   upon   in    1909  and 
1910,  428 
to  end  of  1908,  317 
Cholecystitis,     subacute     duodenal 
perforation    and,    differentiation, 
246 
Cholecysto-duodenal  fistula,  305 

cases,  327,  377,  412 
Choledocho-duodenal    anastomosis, 

290,  291,  293 
Cholelithiasis,  adhesions  in,  148 
chronic  ulcer  and,  differentiation, 

139.  146 
pain  in  diagnosis  of,  146 
with  chronic  ulcer,  326,  330,  375, 
378,  398,  411-  421 
Chyme,   regurgitation  of,   in   ulcer, 

130 
Cicatricial     involvement     of    other 

structures,  296 
Circular  duodenal  ulcer,  280,  281 


Index 


475 


Circular  duodenal  ulcer  from  burns, 
40 

Cirrhosis   of   liver,    duodenal    ulcer 
and,  differentiation,  156 

Climate,  attacks  of  pain  and,  141 

Colon    and    duodenum,    fistula   be- 
tween, 309 

Common  duct,  closure  of,  by  steno- 
sis, 282,  284 
involvement    in   chronic   ulcer, 

299 
perforation  of,  299 
Contact  ulcers,  279 
Contractile  power  of  duodenum,  136 
Curling's  ulcer,  25.     See  also  Burns, 
duodenal  ulcer  from 


Deep  ulcer  from  burn-.  40 
Diagnosis,  107,  112,  115 
differential,  139 
examination  of  patient,  115 
from    symptoms    alone,    earliest 

case,  20,  2T, 
haemorrhage  in,  155,  156 
summary,  137 
Differential  diagnosis,  139 
Digestion   in  chronic  ulcer  as  seen 

by  x-ray,  133,  134 
Dilatation,     duodenal,     in    chronic 
ulcer,  136 
of  stomach  in  ulcer,  117 
Diverticula  from  pouching  of  ulcer, 
268,  270,  271 
pseudo,  271 
Diverticulum  of  Vater,  stenosis  of, 

from  ulcer,  282 
Duodenal  anthrax,  53,  54 
contratf  ile  power,  136 
dilatation  in  ulcer,  136 
fistula,  Berg's  treatment,  252 
cases,  252 

gastro-enterostomy  with  occlu- 
sion of  pylorus  tor,  252 
in  chronic  perforation,  248,  251 
kink,  185 

in  ulcer,  13.S.  i.V- 


Duodenal  stasis  in  ulcer,  136 
ulcer,  acute,  perforation  in,  215 
age  and,  317,  428 
annular,  280,  281 
cases   operated    upon    in    1909 
and  1910,  428 
to  end  of  1908,  317 
causes,  154 
chronic,  107 

abdominal     wall,     liver,     or 

pancreas  as  base,  245 
absence  of  excess  of  hydro- 
chloric acid  in,  121,  130 
acid  dyspepsia  and,  114,  119- 
124, 129 
gastritis  and,  1 14,  1 19-124, 
129 
adhesions  in,  268 
age  and,  107 

anaemia    and,  splenic,  differ- 
entiation, 155,  156 
anamnesis  in,  107 
anastomosis   after   resection, 

161,  163 
aneurysmal  dilatation  in,  301 
annular,    280,  2X1 
anterior  and  posterior,  rela- 
tive frequency,  280 
appearance,  266 
appendectomy  in,  184 
appendicitis  and,  184,  185 
differentiation,  139,  151 
mimicking,  case,  153 
attacks,  112 

causes,  113,  275 

climate  and,  141 

cold  and,  1 13 

first,  conditions  present  in 

duodenum,  158 
length,  113 
periodicity,  108,  1 12 

recurreni  e,  141 
ison  and,  141 

BantiV   disease,    differentia- 
tion, 155,  156 

bismuth  meal-  and  x-ray  in. 
133.  '34 


476 


Index 


Duodenal    ulcer,  chronic,  bleeder's 
disease  and,  156 
blown-out  feeling.  109 
carcinoma  from,  311 
cardiospasm    in,    case,    321, 

414.  425 
cases,  339-342. 349-356. 358- 
3/o,    372-379.    381-428, 
432-465 
causes,  154 

of  attacks,  113 
choledocho-duodenal      anas- 
tomosis     in,       290,    291, 

293 

cholelithiasis  and,  differentia- 
tion, 139,  146 

cholelithiasis  with,  324,  326, 
330,  375-  376,  378,  398, 
411,  421,  442 

cicatrical      involvement      of 
other  structures,  296 

circular,  280,  281 

cirrhosis  of  liver  and,  differ- 
entiation, 156 

cold  and,  113,  141 

contact,  279 

crater  of,  267 

death    from    bloodvessel    in- 
volvement, 300 

diagnosis,  107,  112,  115 
differential,  139 
summary,  137 

differential  diagnosis,  139 

dilatation  in,  136 

dyspepsia  and,  appendix,  dif- 
ferentiation, 151 

examination  of  abdomen  in, 
116 
of  patient,   1  15 

excision  for,  161,  164 
cases,  327,  424 
Finney's    operation    after, 

161 
indications,  163 

extension  to  pylorus,  275 

fistula  in,  305 

gall-bladder    adhesions,    267 


Duodenal  ulcer,  chronic,  gall-stones 
and,    differentiation,     139, 
[46 
gall-stones    with,    324,    326, 

330,375.376,378,398.411. 
421,442 
gastric   activity   as   seen  by 
.v-ray,  133,  134 
carcinoma  mimicking,  142, 

143 
dilatation  in,  117 
stasis  in,  117 
ulcer  and,    differentiation, 

139 

gastroenterostomy  for,  161 , 
168.  See  also  Gastro-enter- 
ostomy 

haemophilia  and,  156 

haemorrhage  in,  124,  319, 
429.  See  also  Mcelena  in 
chronic  ulcer 

healing  and  breaking-down 
process,  275 

heartburn  in,  133 

hepatic  cirrhosis  and,  differ- 
entiation, 156 

hunger    pain    in,     109,    133, 

145 
hyperchlorhydria    and,    114, 

1 19-124,  129 
inconspicuous  lesion,  154 
infolding  of,  162,  182 
involvement    of    ampulla    of 
Vater,  282 
of  aorta,  301,  302 
of  arteries,  300 
of  bloodvessels,  300 
of  canal  of  Wirsung,  282, 

286,  299 
of  common  bile-duct,  282, 

284,  299 
of  gastro-duodenal  artery, 

300 
of  gastro-epiploica,  301 
of  hepatic  artery,  301 
of  liver,  285,  287,  299 
of  mesenteric  vein,  304 


Ind 


ex 


477 


Duodenal  ulcer,    chronic,   involve- 
ment of   other   struc- 
tures, 282 
by  cicatrix,  296 
of  pancreas,  282,  298 
of       pancreatico-duodenal 

ulcer,  300 
of  postal  vein,  285,  303 

by  scar,  296 
of  veins,  300 
kink  in,  135,  136 
kissing,  279 

liver  cirrhosis  and,  differentia- 
tion, 156 
locomotor    ataxia    and,    dif- 
ferentiation, 150 
malignant  change  in,  275,  3 1 1 
multiple,  278. 
neurosis  and,  1 14 
onset,  113 

operations   for,    death   from, 
327-330,  343.  354-  385, 
391,  429,  465 
inauguration,  22 
results,  327,  430 
statistics,  321,  430 
overwork  and,  1 13 
pain  in,   108,   133.     See  also 

Pain  in  chronic  ulcer 
pathology,  264 
perforation,    216,    320,    429. 

See  also  Perforation 
position  of,  264,  266 
posterior  and  anterior,  rela- 
tive frequency,  280 
pouching  of,  268,  270,  271 
puckering  of,  270,  271 
pylephlebitis  in,  304 
pylorospasm  with,   in,   118, 

323.  366,  416 
regurgitation  of  chyme  in,  130 

of  food,  1 10 
resection  and  anastomosis  in, 

1 '  - 1 ,  1 63 
saliva  in.  1 10 
sex  and, 

266,  260 


Duodenal  ulcer,  chronic,  solitary,  on 
posterior  surface,  280 

splenic   anaemia   and,    differ- 
entiation, 155,  156 

stasis  in,  136 

stenosis  in,  112,  320,  429 
from  closure  of  perforation, 
239 

sudden  death  in,  300 

symptoms,     107,     318.     See 
also  Symptoms 

tabes    and,    case,    429,    431, 

454 
differentiation,  150 
tenderness  in,  116,  141 
termination,  1 13 
terraced,  268 
test  meal  in,  118 
tetany  in,  321 
thrombosis    of    portal    vein 

from  scar,  296 
toxic  process  and,  154 
treatment,      158.     See     also 

Treatment  of  chronic  ulcer 
tucked  back,  108,  264 
undetected,  324,  417 
variations  in  type,  131 
vomiting      after      operation, 
cases,  333,  337,  344,  349, 
351-    355-    360,    363,    372, 
374.    382,    386,    387,    431, 
432,  440,  459 
vomiting  in.  112,  132 
waterbrash  in,  133 
wet  feet  and,  1 13 
worry  and,  1 13 
.v-ray  in,  133 
circular,  280,  281 
from  burns,  40 
com. km  ,  279 
Curling's,  25.     See  also  Bums. 

duodenal  ulcer  from 
deep,  from  burns,  40 
diagnosis,  107,  112,  115 
diffcrrnii.il,   [39 
from    symptoms    alone,    first 


478 


Index 


Duodenal     ulcer,     diagnosis,    sum- 
mary, 137 
differential  diagnosis,  139 
earliest  recorded  cases,  17 
early  literature,  17 
from  burns,  24.     See  also  Burns, 

duodenal  ulcer  from 
from      scalds,      24.     See      also 

Burns,  duodenal  ulcer  from 
gastric  ulcer  with,  cases,  55,  335- 
339.   341.  342,  344-349. 
351-353.    355-357.    367. 
369.  371-373.  375.  379- 
380,  383,  384,  386,  389, 
395,  401,  402,  404,  406, 
409,  419,  423,  435,  436, 
442,  446,  451-453,  459, 
461 
resection  for,  104 
history,  17 
hunger  pain  in,  109,  133 

causes,  1 14 
impinging  of  acid  chyme  and, 

37 
in  newborn,  85 
cases,  90-106 
causes,  86,  87 
characteristics,  88 
deaths  after  one  week  from 
birth,  100 
within  one  week  from  birth, 

95 

diagnosis,  89 

eczema  and,  10 1 

frequency,  86 

haemorrhage  in,  85.  See  also 
Melcena  neonatorum 

melaena  in,  85.  See  also  Me- 
lcena neonatorum 

mortality,  95 

multiple,  88 

perforation,  88,  89 

position,  88 

prognosis,  95 

symptoms,  89 

thrombosis  and,  87 

treatment,  91 


Duodenal  ulcer  in  pemphigus,  54 

in  phthisis,  75 

irregular,  from  burns,  40 

kissing,  279 

multiple,  from  burns,  38 

oval,  from  burns,  40 

perforation   of,   215.     See   also 
Perforation 

relish  for  food  in,  19 

second,  239 

sex  and,  317,  428 

solitary,  from  burns,  38 
uraemic,  51 

superficial,  from  burns,  40 

symptoms,  107,  318.     See  also 
Symptoms 

treatment,  158.    See  also  Treat- 
ment of  chronic  ulcer 

tuberculous,  68.     See  also  Tu- 
berculous duodenal  ulcer 

tucked  back,  108,  264 

typhoid,  52,  54 

uraemic,  44.     See  also   Urcemic 
duodenal  ideer 

variety,  317,  428 
Duodenitis  following  burns,  28 
Duodeno-colic  fistula,  309 
Duodenum,  adherent,  closure  of  per- 
foration by, 244 
and  colon,  fistula  between,  309 
and  gall-bladder,  fistula  between, 

305 
cases,  327,  377,  412 
and     pancreas,    fistula    between, 

306 
and     stomach,    fistula    between, 

3ii 
diverticula  of,  268,  270,  271 
hour-glass,  276 

resection  for,  194 
in    excretion    of    urinary    toxins, 

54 

pseudo-diverticulum  of,  271 
Dyspepsia,  acid,  ulcer  and,  114,  119- 
124,  129 

appendix,  chronic  ulcer  and,  differ- 
entiation, 151 


Ind 


ex 


479 


Early  literature,  17 

Eczema  in  newborn,  duodenal  ulcer 
and,  101 

Emboli,  ulcer  from  burns  and,  38 

End-to-side    anastomosis    after    re- 
section for  chronic  ulcer,  161,  163 

Enema     after     gastroenterostomy, 
191 

Enteritis  in  uraemic  ulcer,  47 

Excision  for  chronic  ulcer,  1 61,  164 
Finney's  operation  after,  161 
indications,  163 
for  jejunal  ulcer,  203, 21 1, 212,  213 

Excretory     activity     of     intestinal 
tract,  uraemic  ulcers  and,  54 


Finney's   operation"  after  excision, 

161 
Fistula,  305 

cholecysto-duodenal,  305 

cases,  327,  377,  412 
duodenal.  Berg's  treatment,  252 
cases,  252 

gastroenterostomy  with  occlu- 
sion of  pylorus  for,  252 
in  chronic  perforation,  248,  251 
duodeno-colic,  309 
external,  31 1 
from  burns,  308 
gastro-duodenal,  311 
pancreatico-duodenal,  306 
Food,  appendix  dyspepsia  and,  151 
effect  of,  on  pain  in  chronic  ulcer, 

108,  109,  1 10 
liquid,  ulcer  pain  and,  108,  112 
regurgitation  in  chronic  ulcer,  no 
relish  for,  19 
Forsyth  device  for  keeping  patienl 
in  sitting  position,   1 88 


Gall-bladder  adhesions  in  chronic 

ulcer,  207 
and  duodenum,  fistula  between, 

305 

327,  377,  4'-? 


Gall-bladder  calculi  with  duodenal 
ulcer,  324,  376 

perforation,  duodenal  perforation 
and,  differentiation,  230 
Gall-stone    disease.     See  Cholelithi- 
asis 
Gastric.     See  Stomach 
Gastritis,  acid,  duodenal  ulcer  and, 

114,  119-124,  129 
Gastro-duodenal      artery,     involve- 
ment in  chronic  ulcer,  300 

fistula,  311 
Gastroenterostomy,  166,  167,  168 

after-treatment,  187,  240,  241 

Allis'  forceps  in,  175 

anastomosis  in,  part  for,  169 

anterior,  187,  325,  343,  409 

antiperistaltic  method,  322 

appendectomy  with,  184,  201 

attachment  of  jejunum  to  stom- 
ach after,  181,  184 

basting  stitch  in,  175 

bowels  after,  191,  193 

closing  lesser  sac  in,  181 

diet  after,  189 

enema  after,  191 

for  carcinoma,  case,  1 97 

Forsyth's  device  for  keeping  pa- 
tient   in    sitting    position,    188 

gastro-jejunal    ulcer    after,     196. 
See  also  Jejunal  ulcer 

gastroplasty  with,  327,  389 

getting  up  after,  194 

in  duodenal  perforation,  239 

in  gastric  crises  of  tabes  dors;ili-, 
150,  151 

in  periduodenal  abscess,  252 

indications,  161 

infolding  ulcer  in,   [82 

jejunal  ulcer  after,  [96.     See  also 
Jejunal  ul,  er 

loop-on-mucosa  stitch  in,   177 

morphine  after,  101 

mortality,  [96 

Moynihan's       modification       of 

Roux's      operation,      [go,      102, 
193 


480 


Index 


Gastroenterostomy.  Murphy's  rec- 
tal infusion  after,  240 
new    ulcer   after,    196.     See   also 

Jejunal  ulcer 
no-loop  method,  168 
perforation  after,  161 
position  of  patient  after,  188 
posterior,  168 

return  of  symptoms  after,  161 
Roux's,  188,  189 

Moynihan's  modification,   190, 
192,  193 
running  stitch  in,  177 
solid  food  after,  191 
statistics,  321 

sutures  in,  172,  173,  175,  180 
inner,  175 

needles  for,  172,  173 
outer,  173 
thirst  after,  191 
visceral  incision  in,  174 
Von  Hacker's,  168 
with  Laplace's  forceps,  322,  335 
with  pyloric  occlusion  in  duodenal 
fistula,  252 
Gastro-epiploica,     involvement,    in 

chronic  ulcer,  301 
Gastro-jejunal  ulcer,  196.     See  also 

Jejunal  ulcer 
Gastroplasty    with    gastroenteros- 
tomy, 327,  389 
Gnawing  pain  in  chronic-  ulcer,  no 


Hamatemesis.     See  Mcelena 
Haemophilia,  chronic  ulcer  and,  156 
1  hemorrhage.     See  Mcelena 
Hemorrhagic  erosions,  uremic  duo- 
denal nicer  and,  54 
Harrington's   solution  in   preparing 

for  operation,  234 
Heartburn  in  chronic  ulcer,  133 
Helmhol/.'s      theory     of     duodenal 

ulcer  in  infancy,  87 
Hepatic      artery,      involvement    in 
chronic  ulcer,  301 


Heptic    cirrhosis,     duodenal     ulcer 

and,  differentiation,  156 
History,  17 
Hour-glass  duodenum,  276 

resection  for,  194 
stomach,  276 

case,  277 

with  duodenal  ulcer,  cases,  327, 

389 
Hunger  pain,  109,  133,  145 

cause,  114 
Hyperacidity.       See    Hyperchlorhy- 

dria 
Hyperchlorhydria    as    symptom    of 
various  diseases,  122,  124 
chronic  ulcer  and,  114,  129 
duodenal  ulcer  and,  1 19-124 
geographic  factor,  121,  124 
in  gastric  carcinoma,  124 


Incompetency,    gastric,    in    ulcer, 

117 
Infolding  ulcer,  162,  182 
Inspection     of     body     in     earliest 

recorded  case,  18 
Irregular  ulcer  from  burns,  40 


Jaundice  from  stenosis  due  to  ulcer, 

282 
Jejunal  ulcer,  196 

cases,  204-214,  431,  463 
cause,  200 

developed  rapidly,  201 
slowly,  202 

within  few  weeks,  202 
excision  for,  203,  211,  212,  213 
frequency,  196 

after  various  forms  of  gastro- 
enterostomy, 198 
perforation,  case,  199 
perforation    in,    subacute,    202 

into  hollow  viscus,  203 
position,  197 
suture  material  and,  200 
time  of  appearance,  198 


Index 


481 


Jejunal  ulcer,  treatment,  203.     See 
also  Treatment  of  jejunal  ulcer 
types,  201 
Jejunum,  antiperistaltic  application 
of,  to  stomach,  181,  184 


Kink,  duodenal,  185 
Kissing  ulcers,  279 
treatment,  161 


Lane's  kink,  185,  187 
Lavage  after  operation  for  duodenal 
perforation,  236,  237 
tube,  237,  238 
Liquid  diet,  ulcer  pain  and,  108,  112 
Liver  as  base  of  duodena]  ulcer,  246 
cirrhosis  of,  duodenal  ulcer   and, 

differentiation,  156 
involvement    in    duodenal    ulcer, 
285,  287,  299 
Locomotor   ataxia,    duodenal    ulcer 

and,  differentiation,  150 
Loop-on-mucosa    stitch    after    exci- 
sion, 167 
in  gastroenterostomy,  177 
L\  mph  -ealing  duodenal  perforation, 
244 


Medical  ulcer,  154 

Melaena  in  chronic  ulcer,  124,  319, 

429 
(hie!"  symptoms,  131 
death  from,  126 

(fleets  of,   126 

fatal,  [28 
frequency,  124 
insidious,  127 
occult,  127,  128 
onsel .  1 26 
prevention,  125 
sudden,  12s 
symptoms,  126 
unrecognized,  127 
Is  eroded,  [28 


Melsena  in  diagnosis,  155,  156 
in    differentiating    duodenal    and 

gastric  ulcer,  142 
in  gastric  ulcer,  death  from,  126 

effects,  126 
in  ulcer  from  burns,  42 
in  uramic  ulcer,  44,  47 
neonatorum  and  duodenal  ulcer, 

85 
cases,  90-106 

deaths    after    one    week     from 
birth,  100 

within  one  week  from    birth, 

95 
frequency.  85 
mortality,  95 
onset,  85,  86 
prognosis,  95 
transfusion  in,  91 
treatment,  91 
splenic  anaemia  and,   155,   156 
submucous,    uraemic    ulcers   and, 
52 
Mesenteric  vein,  superior,   involve- 
ment in  chronic  ulcer,  304 
Mesocolic  band,  169 
Miliary  tuberculosis  of  duodenum, 

68 
Morphine  after  gastroenterostomy, 
191 
before  operation    lor   perforation, 

234 
in  perioral  inn.  222 
Mouth,  uraemic  ulcer  of,  44 
Moynihan's  curved  needle,  172 
modification    of    Roux's    gastro- 
enterostomy, [90,  K)2.  [93 
Murphy   button   anastomosis,    ^22. 

336 

continuous    rectal    infusion    alter 

gasi  ro-entcrostomy,  240 


\i  1  hi  i- .  Moj  nihan's,  1  72 
Nephritis,    uraemic   duodenal    ulcer 

and, 44 


482- 


Index 


Neurosis,  ulcer  and,  114 

Newborn,  duodenal  ulcer  in,  85. 
See  also  Duodenal  nicer  in  new- 
born 

No-loop  gastroenterostomy,  168 


( >MENTUM,     plugging    of    duodenal 
perforation  by,  243 
police  capacity  of,  269 
Oval  ulcer  from  burns,  40 


Pain,  hunger,  109,  133,  145 
cause,  1 14 
in  cholelithiasis,  146 
in  chronic  ulcer,  108,  116,  133 
appetite  and,  111 
belching  to  relieve,  no 
boring,  no 
burning,  no 
colicky,  1 1 1 
cramp-like,  1 1 1 
diagnostic  value,  108 
food  and,  108,  109,  no 
gnawing,  1 10 
hunger,  109,  114 
liquid  diet  and,  108,  112 
meals  and,  108 
pressure  for  relief,  no 
relief  from  food,  108 
waking  of  patient    by,    109, 
no 
in  differentiation  of  duodenal  and 
gastric  ulcer,  141 
ulcer  and  cholelithiasis,  146 
of  gastric  from  duodenal  ulcer, 

139 
in  gastric  ulcer,  site  of,  141 
in  perforation,  219,  225 

subacute,  244 
on  lefl  side,  1 16 
Bite  of,  141 
Pancreas,  abscess  of,   in   duodenal 

ulcer,  23 
and  duodenum,   fistula   between, 

306 


Pancreas  as  base  of  duodenal  ulcer, 
246 
involvement  by  duodenal    ulcer, 
282,  298 
Pancreatico-duodenal     artery,      in- 
volvement    in    chronic    ulcer, 
300 
fistula,  306 
Pancreatitis,    duodenal    perforation 

and,  differentiation,  228 
Pathology  of  chronic  ulcer,  264 
Pemphigus,  uraemic  ulcer  in,  54 
Perforation,  215,  320,  429 
acute,  of  chronic  ulcer,  216 
after  gastroenterostomy,  161 
age  and,  215 
cases,  258-263 
in  ulcer  from  burns,  42,  215 
of  acute  ulcer,  215,  216 
of  arteries,  300 
of  bloodvessels,  300 
of  canal  of  Wirsung,  299 
of  chronic  ulcer,  216 

abdomen  in,  220,  222 
acute,  216 

appendicitis  and,  differentia- 
tion, 222,  227 
bronchitis    and,    differentia- 
tion, 230 
cause,  218 
chronic,  247 

fistula  in,  248,  251 
periduodenal     abscess    in, 
247,  248 
course,  219 

differential  diagnosis,  225 
direction  of  flow  of  fluid,  223 
drainage  after  operation,  238 
first  operations  for,  21,  241 
fluid  from,  course  of,  223 
gall-bladder  perforation  and, 

differentiation,  230 
gastric  perforation  and,  dif- 
ferentiation, 226 
gastroenterostomy  in,  239 
Harrington's  solution  in  prep- 
aration for  operation,  234 


Index 


483 


Perforation  of  chronic  ulcer,  mimick- 
ing appendicitis,  222,  227 
morphine    before    operation, 

234 

morphine  in,  222 

mortality    of    operation    for, 
241 

operation  for,  234 

emptying    stomach    after, 

236 
first  case,  21,  241 
lavage  after,  236,  237 

pain  in,  219,  225 

pancreatitis     and,     differen- 
tiation, 228 

pleurisy  and,'  differentiation, 
230 

pneumonia   and,   differentia- 
tion, 230 

prevention,  217 

prognosis,  221 

pulse  rate  in,  220,  221 

rigidity  in,  226 

scopolamine  before  operation, 

234 
second  ulcer  and,  239 
stenosis     from     closure      of, 

239 
subacute,  242 

abdominal  wall,  liver,  and 
pancreas  as  base  of  ulcer, 
246 

adhesions  in,  244 
5,  259,  387 

cholecystitis  and,  differ- 
entiation, 246 

complications  when  oper- 
ation is  not  performed, 

245 
differentia]  diagnosis,  246 
empty  stomach  and,  243 
localization  of  Quids,  242, 

^43 
pain  in,  244 

plastic  lymph  sealing,  244 
plugging    of    opening    by 

omental  tag,  243 


Perforation  of   chronic  ulcer,  sub- 
acute,   secondary     rup- 
ture, 245 
symptoms,  244 
treatment,  246 
sudden  death  from,  219 
symptoms,  219 

of  complications,  221 
tenderness  in,  220,  221 
thoracic  disease  and,  230 
toilet    of    peritoneum    after 

operation,  236 
treatment,  233 

preparation  of  patient,  234 
two  at  same  time,  281 
with  abscess  cavity  between 
pancreas  and  duodenum,  23 
without  previous  symptoms, 
217.  225 
of  common  duct,  299 
of    duodenal    ulcer,    appendicitis 

with,  228 
of  gall-bladder,  duodenal  perfor- 
ation and,  differentiation,  230 
of  jejunal  ulcer,  case,  199 
into  hollow  viscus,  203 
subacute,  202 
of  ulcer  in  newborn,  88,  89 
of  uraemic  ulcer,  48 
of  veins,  300 
Periduodenal  abscess  after  subacute 
perforation,  245 
burrowing  of,  24.S 
in  chronic  perforation,  247,  248 
pus  in.  course  of,  249 
rupture  of,  248 
treatment ,  25  1 
Peritoneum  in  earliest  cases,  18 
toilet  after  operation  for  duodenal 
perforation,  236 
Phthisis,  duodenal  ulcer  in,  1  ases,  75 

Plastic   lymph   sealing   perforation, 

244 
Pleurisy,  duodenal  perforation  and, 

differentiation,  230 

ing  of  perforation  by  omental 
243 


484 


Index 


Pneumonia,    duodenal    perforation 

and.  differentiation,  230 
Police  capacit}  of  omentum,  269 
Portal     vein,     involvement    of,    by 
duodenal  ulcer,  285,  303 
in  rir.it  rix,  296 
thrombosis  of,  from  scar,  296 
Post-operative  vomiting,  cases,  333, 

337-  344.  349.  35i.  355.  36o.  363. 
372,  374,  382,  386,  387,  431,  432, 

44".  459 
Pouching  of  chronic  ulcer,  268,  270, 

-"7i 
Proctoclysis,  Murphy's,  after  gastro- 
enterostomy, 240 
Pseudo-diverticulum  of  duodenum, 

271 
Pulmonary    tuberculosis,    duodenal 

ulcer  in,  75 
Pylephlebitis  in  chronic  ulcer,  304 
Pyloric  spasm. in  chronic  ulcer,  11 1, 
118,  323,  366,  416 

vein,  265 
Pylorus    left    intact    with    duodenal 
resection,  194 

occlusion  of,  with  gastroenteros- 
tomy in  duodenal  fistula,  252 

vein  showing  position  of,  265 


Regurgitation  of  chyme  in  chronic 
ulcer,  150 
of  food  in  chronic  ulcer,  no 
Relish  for  food,  19 
Resection      and      anastomosis      in 
chronic  ulcer,  161,  163 
for    chronic    ulcer    with    gastric 

ulcer,  194 
for  gastric   ulcer  with   duodenal, 

194 
for  hour-glass  duodenum,   194 
leaving  pylorus  intact,  194 
of  anastomosis  for  jejunal   ulcer, 

203 
of  jejunal  ulcer,  t ransgastric,  204 
with  portion  of  stomach,  194 
without  portion  of  stomach,  194 


Rout  gen  ray  in  chronic  ulcer,  133 
Roux's  gastroenterostomy,  188,  189 
Moynihan's   modification,    190, 
192,  193 
method  in  jejunal  ulcer,  203 


Saliva,  flow  of,  in  chronic  ulcer,  no 
Scalds,    duodenal    ulcer    from,    24. 

See    also    Burns,    duodenal    ulcer 

from 
Scopolamine    before    operation    for 

perforation,  234 
Season,  attacks  of  pain  and,  141 
Sex,  duodenal  ulcer  and,  108 
Skin,  ursemic  ulcer  of,  44 
Solitary  uraemic  ulcer,  51 
Spasm,  pyloric,  in  chronic  ulcer,  1 1 1 , 

118,  323,  366,  416 
Splenic  ana?mia,  chronic  ulcer  and, 

differentiation,  155,  156 
Stasis,  duodenal,  in  ulcer,  136 

gastric,  in  ulcer,  1 17 
Stenosis,  double,  of  duodenum,  277, 
278 

from  closure  of  perforation,  239 

in  chronic  ulcer,  112,  276,  320,  429 

of    diverticulum    of    Yater    from 
ulcer,  282 
Stomach  activity  in  chronic  ulcer  as 
seen  by  x-ray,  133,  134 

and  duodenum,   fistula  between, 

3ii 

antiperistaltic  application    of    je- 
junum to,  181,  184 

carcinoma    of,     hyperchlorhydria 
in,  124 
mimicking  duodenal  ulcer,  142, 

143 
contents,    absence    of    excess    of 

hydrochloric  acid  in  ulcer,  121, 

130 
dilatation  of,  in  ulcer,  117 
empty,  duodenal  perforation  and, 

243 
emptying    of,    at    operation    for 
duodenal  perforation,  236 


Index 


48: 


Stomach,  hour-glass,  276 
case,  277 
with  duodenal  ulcer,  cases,  327, 

389      ' 
motor  incompetence  of,  in  ulcer, 

H7 
resection  of,  with  duodenum,  194 
ulcer,  appendicitis  and,  differen- 
tiation, 151,  152 
attacks,  recurrence,  141 
carcinoma  from,  311 
causes,  154 

duodenal  ulcer  and,  differentia- 
tion, 139 
ulcer  with,  55 

cases,  335,  339,  341,  342, 
344.349.351.352,353. 
355.  356,  357.  367, 
369, 
375. 
384. 
401, 

409. 
436, 
452, 

resection  for,  194 
from  burns,  39 
hemorrhage  in,  death  from,  126 

effects,  126 
pain  in,  site  of,  141 
perforation   of.    drainage   after 
operation,  238 
duodenal     perforation     and, 
differentiation,  226 
toxic  process  and,  154 
uraemic  ulcer,  44,  55 
Sudden  death  from  perforation,  219 
Superficial  ulcer  from  burns,  40 
Superior  mesenteric   vein,   involve- 
ment in  chronic  ulcer,  304 
Symptoms,  107,  318 
blow  u-out  feeling,  too 
definiteness  of,  107 

t\iu-  to  burns,  41 
I  lie-t   literat  lire,  22 

earlj .  108 

long  standing,  [07 


371. 

37-1. 

373. 

379, 

380, 

383. 

386, 

389, 

395- 

402, 

404. 

406, 

419. 

423. 

435. 

142> 

446, 

45i. 

453. 

459. 

461 

Symptoms,  onset.  I  13 
periodicity,  108,  1 12 
relief  after  meals,  108 
termination.  1 13 
without  lesion,  149 


Tabes,    duodenal   ulcer  and.  cases, 

429,431,454 
differentiation,  150 
Tenderness  in  chronic  ulcer,  1 16,  141 
in   differentiating  duodenal  from 
gastric  perforation,  226, 
227 
ulcer,  141 
in  perforation.  220.  221 
Terraced  chronic  ulcer,  268 
Test-meal  in  duodenal  ulcer,  118 
Tetany  in  ulcer,  321 
Thirst  after  gastroenterostomy,  191 
Thoracic   disease,   duodenal   perfor- 
ation and, 230 
Thrombosis,  duodenal  ulcer  in  new- 
born and,  87 
of  portal  vein  from  cicatrix,  296 
Toluylenediamine    injections,    ulcer 

from  burns  and,  36 
Toxic  process,  ulcer  and,  154 
Transfusion    of    blood    in    melaena 

neonatorum.  <>t 
Transgastric     resection    of    jejunal 

ulcer,  204 
Treatment,    mortality   from   opera- 
tion, cases,   327-330.   343,  354. 
385,  391,  430,  465 
of  chronic  ulcer.   [58 

anastomosis   after   resection, 

161,  163 
appendectomy  in.  [84 
by  excision,  [61,  [64 

Finney's   operation    after, 

[61 
indications,  [63 
by  gastroenterostomy,    [61 
[68.     See  aUu  Gastro-enter- 

■my 


486 


Index 


Treatment  of  chronic  ulcer  by  re- 
section   and    anastomosis, 
161 
choice  of  operation,  160,  164 
indications     for     operation, 

[58 
infolding  of,  162,  182 
medical,  158,  159,  160 

vs.  surgical,  158 
perforation  after  gastroenter- 
ostomy, 161 
surgical,  160 
indications,  158 
vs.  medical,  158 
when  to  operate,  158 
of  jejunal  ulcer,  203 

by  excision,  203,  211,212,213 
by  resection  of  anastomosis, 
203 
transgastric,  204 
Roux's  method,  203 
of  kissing  ulcers,  161 
of  melaena  neonatorum,  91 
of  perforation,  233 
of  ulcers  from  burns,  42 

in  newborn,  91 
results,  327,  430 

statistics  of  operations,  321,  430 
Tuberculous  duodenal  ulcer,  68 
cases,  74,  75-84 
causes,  75 
position,  74 
symptoms.  7  1 
types,  69,  74 
Tucked  back  ulcers,  108,  264 
Typhoid  ulcer,  52,  54 


I  iirs  carcinomatosum,  275,  311 
Umbilicus,  uraemic  ulcer  of,  44 
Uraemic  duodenal  ulcer,  44 
burns  and.  55 
cases,  46,  54-67 
causes,  45,  46,  51 
death  from,  51 
depth  of,  51 
enteritis  in,  47 
haemorrhage  in,  44,  47 
haemorrhagic  erosions  in,  54 
history,  44 
perforation,  48 
position,  44,  50 
solitary,  51 
ulcer  of  anus,  44 
of  mouth,  44 
of  skin,  44 
of  stomach,  44,  55 
of  umbilicus,  44 
Urinary    toxins,    duodenum    in    ex- 
cretion, 54 


Veins,      involvement,     in     chronic 

ulcer,  300 
Vomiting  in  chronic  ulcer,  112,  132 
post-operative,    cases,    333,    337, 
344,   349,   35L   355-   36o,   363, 
372,   374,   382,   386,   387,   431, 
432,  440,  459 
Von    Hacker's    gastro-enterostomy, 
168 


Waterbrash  in  chronic  ulcer,   133 


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"  He  has  shown  good  judgment  in  the  selection  of  his  data.  He  has  placed  most  emphasis 
on  diagnostic  and  therapeutic  aspects.  He  has  presented  his  facts  in  a  manner  to  be  readily- 
grasped  by  the  general  practitioner." 


Bandler's   Vaginal   Celiotomy 

Vaginal  Celiotomy.  By  S.  Wyllis  Bandler,  M.  D.,  New  York 
Post-Graduate  Medical  School  and  Hospital.  Octavo  of"450pages,  with 
148  original  illustrations.     Cloth,  £5.00  net;  Half  Morocco,  $6.50  net. 

SUPERB  ILLUSTRATIONS 

The  vaginal  route,  because  of  its  simplicity,  ease  of  execution,  absence  of 
shock,  more  certain  results,  and  the  opportunity  for  conservative  measures,  con- 
stitutes a  field  which  should  appeal  to  all  surgeons,  gynecologists,  and  obstetricians. 
Posterior  vaginal  celiotomy  is  of  great  importance  in  the  removal  of  small  tubal 
and  ovarian  tumors  and  cysts,  and  is  an  important  step  in  the  performance  of 
vaginal  myomectomy,  hysterectomy,  and  hysteromyomectomy.  Anterior  vaginal 
celiotomy  with  thorough  separation  of  the  bladder  is  the  only  certain  method 
of  correcting  cystocele. 

The  Lancet,   London 

"  1  >r.  Bandlei  has  done  good  ■■•  rvi<  e  in  writing  this  book,  which  gives  .1  very  clear  descrip- 
tion of  all  the  operations  which  may  bi  undertaken  through  tiv  vag  na.  He  makes  oul  a 
strong  case  for  these  operations." 


SAUNDERS'    BOOKS   ON 


Kelly  and   Noble's 

Gynecology 

and  Abdominal  Surgery 

Gynecology  and  Abdominal  Surgery.  Edited  by  Howard  A. 
Kelly,  M.  D.,  Professor  of  Gynecology  in  Johns  Hopkins  University ; 
and  Charles  P.  Noble,  M.  D.,  formerly  Clinical  Professor  of  Gyne- 
cology in  the  Woman's  Medical  College,  Philadelphia.  Two  imperial 
octavo  volumes  of  950  pages  each,  containing  880  illustrations,  some  in 
colors.     Per  volume:  Cloth,  $8.00 net;  Half  Morocco,  $9.50  net. 

TRANSLATED  INTO  SPANISH 
WITH   880   ILLUSTRATIONS    BY  HERMANN   BECKER  AND   MAX   BRODEL 

In  view  of  the  intimate  association  of  gynecology  with  abdominal  surgery  the 
editors  have  combined  these  two  important  subjects  in  one  work.  For  this  reason 
the  work  will  be  doubly  valuable,  for  not  only  the  gynecologist  and  general  prac- 
titioner will  find  it  an  exhaustive  treatise,  but  the  surgeon  also  will  find  here  the 
latest  technic  of  the  various  abdominal  operations.  It  possesses  a  number  of 
valuable  features  not  to  be  found  in  any  other  publication  covering  the  same  fields. 
It  contains  a  chapter  upon  the  bacteriology  and  one  upon  the  pathology  of  gyne- 
cology, dealing  fully  with  the  scientific  basis  of  gynecology.  In  no  other  work 
can  this  information,  prepared  by  specialists,  be  found  as  separate  chapters. 
There  is  a  large  chapter  devoted  entirely  to  medical  gynecology  written  especially 
for  the  physician  engaged  in  general  practice.  Heretofore  the  general  practitioner 
was  compelled  to  search  through  an  entire  work  in  order  to  obtain  the  information 
desired.  Abdominal  surgery  proper,  as  distinct  from  gynecology,  is  fully  treated, 
embracing  operations  upon  the  stomach,  upon  the  intestines,  upon  the  liver  and 
bile-ducts,  upon  the  pancreas  and  spleen,  upon  the  kidneys,  ureter,  bladder,  and 
the  peritoneum.  The  illustrations  are  truly  magnificent,  being  the  work  of  Mr. 
Hermann  Becker  and  Mr.  Max  Br'ddel. 

American  Journal  of  the  Medical  Sciences 

"  It  is  needless  to  say  that  the  work  has  been  thoroughly  done :  the  names  of  the  authors 
and  editors  would  guarantee  this ;  but  much  may  be  said  in  praise  of  the  method  of  presen- 
tation, and  attention  may  be  called  to  the  inclusion  of  matter  not  to  be  found  elsewhere." 


G  YNECOLOG  Y  AND  OBSTETRICS 


Webster's 
Text-Book  qf  Obstetrics 

A  Text=Book  of  Obstetrics.  By  J.  Clarence  Webster,  M.  D. 
(Edin.),  F.  R.  C.  P.  E.,  Professor  of  Obstetrics  and  Gynecology  in  Rush 
Medical  College,  in  affiliation  with  the  University  of  Chicago.  Octavo 
volume  of  767  pages,  illustrated.  Cloth,  $5.00  net;  Half  Morocco, 
$6.50  net. 

BEAUTIFULLY     ILLUSTRATED 

In  this  work  the  anatomic  changes  accompanying  pregnancy,  labor,  and  the 
puerperium  are  described  more  fully  and  lucidly  than  in  any  other  text-book  on 
the  subject.  The  exposition  of  these  sections  is  based  mainly  upon  studies  of 
frozen  specimens.  Unusual  consideration  is  given  to  embryologic  and  physiologic 
data  of  importance  in  their  relation  to  obstetrics. 

Buffalo  Medical  Journal 

"  As  a  practical  text-book  on  obstetrics  for  both  student  and  practitioner,  there  is  left  very 
little  to  be  desired,  it  being  as  near  perfection  as  any  compact  work  that  has  been  published." 


Webster's 
Diseases   of  Women 

A  Text-Book  of  Diseases  of  Women.  By  J.  Clarence  Webster, 
M.  D.  (Edin.),  F.  R.  C.  P.  E.,  Professor  of  Gynecology  and  Obstetrics 
in  Rush  Medical  College.  Octavo  of  712  pages,  with  372  text-illustra- 
tions and  10  colored  plates.     Cloth,  $7.00  net ;  Half  Morocco,  $8.50  net. 

Dr.  Webster  has  written  this  work  especially  for  the  general  practitioner,  dis- 
cussing the  clinical  features  of  the  subject  in  their  widest  relations  to  general 
practice  rather  than  from  the  standpoint  of  specialism.  The  magnificent  illus- 
trations, three  hundred  and  seventy-two  in  number,  are  nearly  all  original. 

Howard  A.  Kelly    M.  D. 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University. 

"  It  is  undoubtedly  one  of  the  best  work-,  which  has  been  put  on  the  market  within  recent 
years,  showing  from  start  to  finish  Dr.  Webster's  well-known  thoroughness.  The  illustrations 
arc  also  of  the  highest  01 


SAUNDERS'   BOOKS   ON 


Hirst's 
Text-Book  of  Obstetrics 

Just  Ready— The  New  (7th)  Edition 


A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome 
octavo  of  iooo  pages,  with  900  illustrations,  45  of  them  in  colors. 

INCLUDING  RELATED  GYNECOLOGIC  OPERATIONS 

Immediately  on  its  publication  this  work  took  its  place  as  the  leading  text-book 
on  the  subject.  Both  in  this  country  and  in  England  it  is  recognized  as  the  most 
satisfactorily  written  and  clearly  illustrated  work  on  obstetrics  in  the  language. 
The  illustrations  form  one  of  the  features  of  the  book.  They  are  numerous  and 
the  most  of  them  are  original.  In  this  edition  the  book  has  been  thoroughly  revised. 
Recognizing  the  inseparable  relation  between  obstetrics  and  certain  gynecologic 
conditions,  the  author  has  included  all  the  gynecologic  operations  for  complica- 
tions and  consequences  of  childbirth,  together  with  a  brief  account  of  the  diagnosis 
and  treatment  of  all  the  pathologic  phenomena  peculiar  to  women. 


OPINIONS  OF  THE   MEDICAL  PRESS 


British  Medical  Journal 

"  The  popularity  of  American  text-books  in  this  country  is  one  of  the  features  of  recent 
years.  The  popularity  is  probably  chiefly  due  to  the  great  superiority  of  their  illustrations 
over  those  of  the  English  text-books.  The  illustrations  in  Dr.  Hirst's  volume  are  far  more 
numerous  and  far  better  executed,  and  therefore  more  instructive,  than  those  commonly 
found  in  the  works  of  writers  on  obstetrics  in  our  own  country." 

Bulletin  of  Johns  Hopkins  Hospital 

"The  work  is  an  admirable  one  in  every  sense  of  the  word,  concisely  but  comprehensively 
written." 

The  Medical  Record,  New  York 

"The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the  first 
time.  The  author's  style,  though  condensed,  is  singularly  clear,  so  that  it  is  never  necessary 
to  re-read  a  sentence  in  order  to  grasp  the  meaning.  As  a  true  model  of  what  a  modern  text- 
book on  obstetrics  should  be,  we  feel  justified  in  affirming  that  Dr.  Hirst's  book  is  without  a 
rival." 


DISEASES   OF    WOMEN. 


HirstV 
Diseases  of  Women 


A  Text=Book  of  Diseases  of  Women.  By  Barton  Cooke  Hirst, 
M.  D.,  Professor  of  Obstetrics,  University  of  Pennsylvania  ;  Gynecolo- 
gist to  the  Howard,  the  Orthopedic,  and  the  Philadelphia  Hospitals. 
Octavo  of  745  pages,  with  701  original  illustrations,  many  in  colors. 
Cloth,  S5.00  net;  Half  Morocco,  $6.50  net. 

THE    NEW   (2d)    EDITION 
WITH    701    ORIGINAL    ILLUSTRATIONS 

The  new  edition  of  this  work  has  just  been  issued  after  a  careful  revision. 
As  diagnosis  and  treatment  are  of  the  greatest  importance  in  considering  diseases 
of  women,  particular  attention  has  been  devoted  to  these  divisions.  To  this  end, 
also,  the  work  has  been  magnificently  illuminated  with  701  illustrations,  for  the 
most  part  original  photographs  and  water-colors  of  actual  clinical  cases  accumu- 
lated during  the  past  fifteen  years.  The  palliative  treatment,  as  well  as  the 
radical  operative,  is  fully  described,  enabling  the  general  practitioner  to  treat 
many  of  his  own  patients  v  ithout  referring  them  to  a  specialist.  An  entire  sec- 
tion is  devoted  to  z.  full  description  of  all  modern  gynecologic  operations,  illumi- 
nated and  elucidated  by  numerous  photographs.  The  author's  extensive  ex- 
perience renders  tnis  work  of  unusual  value. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Medical  Record,  New  York 

"  Its  merits  can  be  appreciated  only  by  a  careful  perusal.  .  .  .  Nearly  one  hundred  pages 
are  devoted  to  technic,  this  chapter  being  in  some  respects  superior  to  the  descriptions  in 
many  other  text-  boks." 

Boston  Medical  and  Surgical  Journal 

1  he  author  has  given  special  attention  to  diagnosis  and  treatment  throughout  the  book, 
and  has  produced  a  practical  treatise  which  should  be  of  the  greatest  value  to  the  student,  the 
general  practitioner,  and  the  specialist." 

Medical   News,  New  York 

"  Office  treatment  is  given  a  due  amount  of  consideration,  so  that  the  work  will  be  as 
useful  to  the  non-operator  as  to  the  spec i  * 


SAUNDERS'    BOOKS   ON 


GET  Ik  •  THE  NEW 

THE  BEST  AmeriCcin  STANDARD 

Illustrated   Dictionary 

New  (6th)  Edition,  Entirely  Reset 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches  ;  with  over  IOO  new  and  elaborate  tables  and  many  handsome 
illustrations.  By  W.  A.  Newman  Dorland,  M.D.,  Editor  of  "  The 
American  Pocket  Medical  Dictionary."  Large  octavo,  986  pages, 
bound  in  full  flexible  leather.  Price,  $4.50  net ;  with  thumb  index, 
$5.00  net. 

IT  DEFINES  ALL  THE  NEW  WORDS-MANY  NEW  FEATURES 


Dorland' s  Dictionary  defines  hundreds  of  the  newest  terms  not  defined  in  any 

other    dictionary — bar    none.      These    new  terms    are  live,  active    words,   taken 

right  from  modern  medical  literature. 

It  gives  the  capitalization  and  pronunciation  of  all  words.      It  makes  a  feature  of 

the  derivation  or  etymology  of  the  words.      In  some  dictionaries  the  etymology 

occupies  only  a  secondary  place,  in  many  cases  no  derivation  being  given  at  all. 

In  "  Dorland,"  practically  every  word  is  given  its  derivation. 

In   "Dorland"   every  word  has  a  separate   paragraph,   thus  making  it  easy  to 

find  a  word  quickly. 

The  tables  of  arteries,   muscles,    nerves,    veins    etc.,    are    of  the   greatest   help 

in  assembling  anatomic   facts.      In  them   are   classified  for  quick  study  all  the 

necessary  information  about  the  various  structures. 

In    "Dorland"    every    word    is    given    its    definition — a    definition    that    defines 

in  the  fewest  possible  words.      In  some  dictionaries  hundreds  of  words  are  not 

defined  at  all,  referring  the.  reader  to  some  other  source  for  the  information  he 

wants  at  once. 

Howard  A.  Kelly,   M.  D.,  Johns  Hopkins   University,  Baltimore 

"  Dr.  Dorland's  dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 

J.  Collins  Warren,  M.  D.,  LL.D.,  F.R.C.S.  (Hon.),  Harvard  Medical  School 

"  I   regard  it  as  a  valuable  aid  to  my  medical  literary  work.     It  is  very  complete  and  of 
convenient  size  to  handle  comfortably.     I  use  it  in  preference  to  any  other." 


GYNECOLOGY  AND    OBSTETRICS  li 

Penrose's 
Diseases  of  Women 

Sixth    Revised    Edition 


A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose, 
M.  D.,  Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of 
Pennsylvania ;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Oc- 
tavo volume  of  550  pages,  with  225  fine  original  illustrations.  Cloth, 
$375  net- 

ILLUSTRATED 

Regularly  every  year  a  new  edition  of  this  excellent  text-book  is  called  for, 
and  it  appears  to  be  in  as  great  favor  with  physicians  as  with  students.  Indeed, 
this  book  has  taken  its  place  as  the  ideal  work  for  the  general  practitioner.  The 
author  presents  the  best  teaching  of  modern  gynecology,  untrammeled  by  anti- 
quated ideas  and  methods.  In  every  case  the  most  modern  and  progressive 
technique  is  adopted  and  made  clear  by  excellent  illustrations. 

Howard  A.  Kelly,  M.D., 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University,  Baltimore. 
"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women  '  received.     I  have 
already  recommended  it  to  my  class  as  the  best  book." 


Davis'  Operative  Obstetrics 

Operative  Obstetrics.  By  Edward  P.  Davis,  M.D.,  Professor  of 
Obstetrics  at  Jefferson  Medical  College,  Philadelphia.  Octavo  of  483 
pages,  with  264  illustrations.     Cloth,  $5.50  net;  Half  Morocco,  $7.00  net. 

INCLUDING  SURGERY  OF  NEWBORN 

Dr.  Davis'  new  work  is  a  most  practical  one,  and  no  expense  has  been  spared 
to  make  it  the  handsomest  work  on  the  subject  as  well.  Every  step  in  every 
operation  is  described  minutely,  and  the  technic  shown  by  beautiful  new  illustra- 
tions.     Dr.  Davis'  name  is  sufficient  guarantee  for  something  above  the  mediocre. 


12  SAUNDERS'    BOOKS   ON 

Dorland's 
Modern   Obstetrics 


Modern  Obstetrics:  General  and  Operative.  By  W.  A.  Newman 
Dorland,  A.  M.,  M.  D.,  Professor  of  Obstetrics  at  Loyola  University, 
Chicago,  Illinois.  Handsome  octavo  volume  of  797  pages,  with  201 
illustrations.     Cloth,  $4.00  net. 

Second  Edition,  Revised  and  Greatly  Enlarged 

In  this  edition  the  book  has  been  entirely  rewritten  and  very  greatly  enlarged. 
Among  the  new  subjects  introduced  are  the  surgical  treatment  of  puerperal  sepsis, 
infant  mortality,  placental  transmission  of  diseases,  serum-therapy  of  puerperal 
sepsis,  etc.  By  new  illustrations  the  text  has  been  elucidated,  and  the  subject  pre- 
sented in  a  most  instructive  and  acceptable  form. 

journal  of  the  American  Medical  Association 

"  This  work  deserves  commendation,  and  that  it  has  received  what  it  deserves  at  the  hands 
of  the  profession  is  attested  by  the  fact  that  a  second  edition  is  called  for  within  such  a  short 
time.     Especially  deserving  of  praise  is  the  chapter  on  puerperal  sepsis." 

Davis'  Obstetric  and 
Gynecologic  Nursing 

Obstetric  and  Gynecologic  Nursing.    By  Edward  P.  Davis,  A.  M., 
M.  D.,   Professor   of  Obstetrics    in   the   Jefferson  Medical   College  and 
Philadelphia   Polyclinic ;    Obstetrician    and    Gynecologist,   Philadelphia 
Hospital.      i2mo  of  436  pages,  illustrated.     Buckram,  $1.75  net. 
THE     NEW    (3d)    EDITION 

Obstetric  nursing  demands  some  knowledge  of  natural  pregnancy,  and  gyne- 
cologic nursing,  really  a  branch  of  surgical  nursing,  requires  special  instruction 
and  training.  This  volume  presents  this  information  in  the  most  convenient 
form.  This  third  edition  has  been  very  carefully  revised  throughout,  bringing  the 
subject  down  to  date. 

The  Lancet,  London 

"  Not  only  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 


GYNECOLOGY  AND    OBSTETRICS. 


Garrigues' 
Diseases  of  Women 

Third  Edition,  Thoroughly  Revised 


A  Text- Book  of  Diseases  of  Women.  By  Henry  J.  Garrigues, 
A.  M.,  M.  D.,  Gynecologist  to  St.  Mark's  Hospital  and  to  the  German 
Dispensary,  New  York  City.  Handsome  octavo,  756  pages,  with  367 
engravings  and  colored  plates.  Cloth,  34.50  net;  Sheep  or  Half 
Morocco,  $6.00  net. 

The  first  two  editions  of  this  work  met  with  a  most  appreciative  reception  by 
the  medical  profession  both  in  this  country  and  abroad.  In  this  edition  the  entire 
work  has  been  carefully  and  thoroughly  revised,  and  considerable  new  matter 
added,  bringing  the  work  precisely  down  to  date.  Many  new  illustrations  have  been 
introduced,  thus  greatly  increasing  the  value  of  the  book  both  as  a  text-book  and 
book  of  reference. 

Thad.  A.  Reamy,  M.  D.,   Projessor  of  Clinical  Gynecology,  Medical  College  of  Ohio. 

"One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in  the 
English  language  ;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning  and 
great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book." 


American  Text-Book  qf  Gynecology 

Second    Revised    Edition 
American   Text=Book  of   Gynecology.     Edited   by  J.    M.    Baldy, 
M.  D.     Imperial  octavo  of  718  pages,  with  341   text-illustrations  and 
38  plates.     Cloth,  $6.oo  net. 

American  Text-Book  qf   Obstetrics 

Second    Revised    Edition 
The  American  Text-Book  of  Obstetrics.     In  two  volumes.    Edited 
by  Richard  C.  Norris,  M.  1). ;  Art  Editor,  Robert  L.  Dickinson,  M.  D. 
Two  octavos  of  about  600  pages  each  ;  nearly  900  illustrations,  includ- 
ing 49  colored  and  half-tone  plates.      Per  volume  :  Cloth,  $3.50  net. 

"  As  an  authority,  a-  a  book  of  reference,  as  a  '  working  book  '  for  the  student  <>r  ]  racti- 
tioner,  we  commend  it  because  we  believe  there  is  no  better." — AMERICAN  JOURNAL  OF  THB 

Medical  s<  11  nces. 


i4  SAUNDERS'    BOOKS   ON 

Schaffer  and  Edgar's  Labor  and  Operative  Obstetrics 

Atlas  and    Epitome   of    Labor    and    Operative    Obstetrics.      By    Dr. 

0.  Schaffer,  of  Heidelberg.  Edited,  with  additions,  by  J.  Clifton  Edgar, 
M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School,  New  York.  With  14  lithographic  plates  in  colors,  139  text- 
cuts,  and  1 1 1  pages  of  text.      Cloth,  #2.00  net.     In  Saunders'  Hand-Atlases. 

American  Medicine 

"  It  would  be  difficult  to  find  one  hundred  pages  in  better  form  or  containing  more 
practical  points  for  students  or  practitioners." 

Schaffer     and     Edgar's     Obstetric     Diagnosis     and 
Treatment 

Atlas  and  Epitome  of  Obstetric   Diagnosis  and   Treatment.     By  Dr. 

O.  Schaffer,  of  Heidelberg.  Edited,  with  additions,  by  J.  Clifton  Edgar, 
M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School,  New  York.  With  122  colored  figures  on  56  plates,  38  text- 
cuts,  and  315  pages  of  text.      Cloth,   $3.00  net.      Saunders'  Hand-Atlases. 

New  York  Medical  Journal 

"  The  illustrations  are  admirably  executed,  as  they  are  in  all  of  these  atlases,  and  the  text 
can  safely  be  commended." 

Schaffer  and  Norris'  Gynecology 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of  Heidel- 
berg. Edited,  with  additions,  by  Richard  C.  Norris,  A.  M.,  M.  D., 
Gynecologist  to  Methodist  Episcopal  and  Philadelphia  Hospitals.  With  207 
colored  figures  on  90  plates,  65  text-cuts,  and  308  pages  of  text.  Cloth, 
$3.50  net.      In  Saunders'  Hand-Atlas  Series. 

American  Journal  of  the  Medical  Sciences 

"  Of  the  illustrations  it  is  difficult  to  speak  in  too  high  terms  of  approval.  They  are  so 
clear  and  true  to  nature  that  the  accompanying  explanations  are  almost  superfluous." 

Galbraith's  Four  Epochs  of  Woman's   Life 

New  (2d)  Edition 

The  Four  Epochs  of  Woman's  Life :  A  Study  in  Hygiene.  By  Anna 
M.  GALBRAITH,  M.  D.,  Fellow  of  the  New  York  Academy  of  Medicine,  etc. 
With  an  Introductory  Note  by  John  H.  Musser,  M.  D.,  University  of 
Pennsylvania.      i:mo  of  247  pages.      Cloth,  $1.50  net. 

Birmingham   Medical  Review,   England 

"  We  do  ii"t,  as  a  rule,  care  for  medical  books  written  for  the  instruction  of  the  public. 
But  we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is,  in  the  main,  wise  and 
wholesome." 


COLUMBIA  UNIVERSITY  LIBRARIES 


0052118711 


GYNECOLOGY  AND    OBSTETRICS. 


r5 


Schaffer  and  Webster's 
Operative  Gynecology 

Atlas  and  Epitome  of  Operative  Gynecology.  By  Dr.  O.  Schaf- 
fer, of  Heidelberg.  Edited,  with  additions,  by  J.  Clarence  Webster, 
M.D.  (Edin.),  F.R.C.P.E.,  Professor  of  Obstetrics  and  Gynecology  in 
Rush  Medical  College,  in  affiliation  with  the  University  of  Chicago. 
42  colored  lithographic  plates,  many  text-cuts,  a  number  in  colors,  and 
138  pages  of  text.     ///  Saunders1  Hand-At/as  Series.    Cloth,  $3.00  net. 


Much  patient  endeavor  has  been  expended  by  the  author,  the  artist,  and  the 
lithographer  in  the  preparation  of  the  plates  of  this  atlas.  They  are  based  on 
hundreds  of  photographs  taken  from  nature,  and  illustrate  most  faithfully  the 
various  surgical  situations.  Dr.  Schaffer  has  made  a  specialty  of  demonstrating 
by  illustrations. 

Medical  Record,  New  York 

"  The  volume  should  prove  most  helpful  to  students  and  others  in  grasping  details  usually 
to  be  acquired  only  in  the  amphitheater  itself." 

De  Lee's 

Obstetrics  for  Nurses 


Obstetrics  for  Nurses.  By  Joseph  B.  De  Lee,  M.D.,  Professor  of 
Obstetrics  in  the  Northwestern  University  Medical  School ;  Lecturer 
in  the  Nurses'  Training  Schools  of  Mercy,  Wesley,  Provident,  Cook 
County,  and  Chicago  Lying-in  Hospitals.  121110  volume  of  5  12  pages, 
fully  illustrated.  Cloth,  $2.50  net. 

THE     NEW    (3d)    EDITION 

While  Dr.  De  Lee  has  written  his  work  especially  for  nurses,  yet  the  prac- 
titioner will  find  it  useful  and  instructive,  since  the  duties  of  a  nurse  often  devolve 
upon  him  in  the  early  years  of  his  practice.  The  illustrations  are  nearly  all 
original,  and  represent  photographs  taken  from  actual  scenes.  The  text  is  the 
result  of  the  author's  many  years'  experience  in  lecturing  to  the  nurses  of  five 
different  training  schools. 

J.  Clifton  Edgar,  M.  D., 

Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University,  New  York. 
"It  is  far  and  away  the  best  that  has  come  to  my  notice,  and  I  shall  take  great  pleasure  in 
recommending  it  to  my  nurses,  and  students  as  well." 


16      SAUNDERS   BOOKS  ON  GYNECOLOGY  AND   OBSTETRICS. 

American  Pocket  Dictionary  New  (7th)  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W. 
A.  Newman  Dorland,  A.  M.,  M.  D.  610  pages,  $1.00  net;  with 
patent  thumb  index,  $1.25  net. 

James  W.  Holland,  M.  D., 

Professor   of  Medical    Chemistry    and    Toxicology    at  the  Jefferson    Medical    College^ 

Philadelphia. 
"  I  am  struck  nt  once  with  admiration  at  the   compact  size  and  attractive   exterior.     I 
can  recommend  it  to  our  students  without  reserve." 

Cragin's  Gynecology.  New  (7th)  Edition 

Essentials  of  Gynecology.  By  Edwin  B.  Cragin,  M.  D., 
Professor  of  Obstetrics,  College  of  Physicians  and  Surgeons,  New 
York.  Crown  octavo,  232  pages,  59  illustrations.  Cloth,  $1.00 
net.     ///   Saunders'   Question- Compcud  Scries. 

The  Medical  Record,  New   York 

"  A  handy  volume  and  a  distinct  improvement  ot  students'  compends  in  general. 
No  author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the 
student's  needs  so  thoroughly  as  Dr.  Cragin  has  done." 

AshtOn*S    Obstetrics.  New  (7th)  Edition 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D., 
Professor  of  Gynecology  in  the  Medico-Chirurgical  College,  Phila- 
delphia. Revised  by  John  A.  McGlinn,  M.  D.,  Assistant  Professor 
of  Obstetrics  in  the  Medico-Chirurgical  College  of  Philadelphia. 
i2moof  287  pages,  109  illustrations.  Cloth,  $1. 00  net.  In  Saunders' 
Question-  Compend  Series. 

Southern  Practitioner 

"  An  excellent  little  volume  containing  correct  and  practical  knowledge.  An  admir- 
able compend,  and  the  best  condensation  we  have  seen." 

Barton  and  Wells'  Medical  Thesaurus 

A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfred 
M.  Barton,  M.  D.,  Assistant  to  Professor  of  Materia  Medica  and 
Therapeutics,  Georgetown  University,  Washington,  D.  C. ;  and 
Walter  A.  Wells,  M.  D.,  Demonstrator  of  Laryngology,  George- 
town University,  Washington,  D.  C.  l2mo  of  534  pages.  Flex- 
ible leather,  $2.50  net ;  with  thumb  index,  $3.00  net. 

Macfarlane's   Gynecology  for  Nurses 

A  Reference  Haxd-Book  of  Gynecology  for  Nurses.  By  Cath- 
ARINE  ,M,\(  1  arlank,  M.  D.,  Gynecologist  to  the  Woman's  Hospital  of 
Philadelphia.  321110  of  150  pages,  with  70  illustrations.  Flexible 
leather,  $1.25  net. 

A.  M.  Seabrook,  M.  D., 

Woman's  Medical  College  of  I'/ii/ade/phta. 

"  It  is  a  most  admirable  little  book,  covering  in  a  concise  but  attractive  way  the  subject 
from  the  nurse's  standpoint." 


DATE  DUE 

Demco.  Inc    33-293 


